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MEDICAL AID SANITARY 



INSPECTION OF SCHOOLS 



FOR THE HEALTH OFFICER, THE PHYSICIAN 
THE NURSE AND THE TEACHER 



BY 

S. W. NEWMAYER, A.B., M.D. 

IN CHAKGE OP DIVISION OF CHILD HYGIENE, BUREAU OF HBALTl}, PHILADELPHIA 



ILLUSTRATED WITH 71 ENGRAVINGS AND 14 FULL-PAGE PLATES 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 



LB34I 
.M4- 



Entered according to the Act of Congress, in the year 1913, by 

LEA & FEBIGER, 
in the ofHce of the Librarian of Congress. All rights reserved. 



/^i/^ 



)CI,A357847 



DEDICATED 
TO 

MY SONS, ALAN AND RICHARD 

AND 

THE OTHER SCHOOL CHILDREN OF AMERICA 



PREFACE. 



We realize that the progress of our civilization, the 
welfare of the individual, and the general good of society 
are contingent upon the efficiency of the education imparted 
to the children in the public schools. To take advantage 
of such opportunities, children must be physically and 
mentally equipped. 

This volume represents an effort to prepare for physi- 
cians, nurses, and teachers a guide to the physical examina- 
tion of school children. The aim is not only to outline 
plans of what and how such work can be best performed, 
but also to develop a deeper appreciation of the relations 
of physical and mental development. Medical inspection 
of schools has more than justified its existence; it has come 
to stay, and have an ever-increasing power of service. 

In these pages the endeavor is to give definite, rational- 
ized plans to prevent epidemics of contagion in the schools, 
and to recognize and correct physical defects of school 
children. Chapters on the sanitation of school buildings 
have received special consideration. Plans of work have 
been formulated to meet all requirements for efficiency, 
time, labor, and money-saving. The author's excuse of 
ability to write this book is twelve years' experience in the 
work of medical inspection of school children and three 
years in charge of the Division of Child Hygiene. 



VI PREFACE 

In the race, to run over the wrong route is worse than 
not to run; so the proper thing is to study the course before 
you start. If these writings prove a trustworthy map to 
those who undertake the work of medical inspection of 
school children I shall feel that my labor is fully repaid. 



CONTENTS. 



INTRODUCTION .... 17 

PART I. 
Administration 23 

PART II. 

The School Buildings and Grounds . 93 

PART III. 

Infectious, Contagious, and Communicable 

Diseases 135 



PART IV. ^ 

Physical Defects .... 165 



MEDICAL INSPECTION OF SCHOOLS. 



INTRODUCTION. 

Public education is a question which vitally concerns 
the national government, as well as every State, city and 
district, and includes within its scope all classes and races. 
In its general management the problem is identical for 
every State, city, and town, but the details, depending as 
they do on surrounding conditions, are chiefly local matters 
coming under the supervision of the local authorities without 
outside interference. In the United States, twenty millions 
of children, or one-fifth of the entire population, are enrolled 
in the public schools. 

The salaries paid to teachers each year amount to more 
than two hundred million dollars, and the total expenditures 
on public schools exceeds four hundred million dollars. Be- 
sides this enormous annual expenditure there is a permanent 
investment in public school buildings amounting to over 
nine hundred million dollars. This requires the levying 
of a heavy taxation on the people. There is a "general" 
tax which is levied on the citizens of the State as a whole 
and a "local" or self-imposed tax levied by each city or 
town. Four-fifths of the school taxes are of this kind. 
That this additional burden is cheerfully borne is ample 
evidence that the people realize the importance of the 
proper education of children. Not only do the people 
give willingly of their income, but many of the best and 
2 



18 MEDICAL INSPECTION OF SCHOOLS 

most influential citizens give their services freely in acting 
as directors for the management of these institutions. To 
make this great expenditure for education effective, there 
must be good teaching, and children physically adapted to 
take advantage of the education offered. 

The progress in medical science, due largely to laboratory 
research and sociological investigation, has brought to light 
the causative factors of disease and demonstrated that many 
are preventable; thus making possible the great advances 
in preventive medicine, sanitation, and hygiene. Dis- 
eases formerly looked upon as visitations of Providence 
are now known to be almost entirely preventable, and the 
preservation of health and life by preventive measures has 
become the watchword of the medical profession. The 
relation of the schools to these achievements of medical 
science is of great importance. These endeavors on the 
part of the medical profession have brought the physician 
in contact with the school, and have claimed his interest in 
educational affairs. The physician soon noted the close 
association between the mental and physical condition 
of the child. Simultaneously, the teacher outgrew the 
early educational methods of teaching en masse, and ad- 
vanced to the modern methods in pedagogy of teaching 
the individual child. Both teacher and physician noted the 
marked variations in the mental capacities of different 
pupils, and recognized the importance of a combined study 
of the causative factors. To them, therefore, medical 
inspection of schools owes its existence. 

Eighteen years of school medical inspection in America 
and almost forty years abroad have carried us beyond the 
question of why such work is needed, and have placed the 
best and most efficient methods and systems within our 
reach. There are still a few doubters and disbelievers, but 



INTRODUCTION 19 

such dissenting voices will always be heard for the same 
reasons that there are people who are opposed to vaccination 
and antitoxins, or progress along any line. The value of 
medical inspection of schools needs no greater endorsement 
than the fact that many of the State legislatures have passed 
laws authorizing the establishing of a system of inspection, 
and in three States medical inspections are mandatory. 

The history of medical inspection of schools includes the 
history of both the school doctor and the school nurse. 
England was one of the first countries to look after the 
physical needs of the school child. There nurses were 
appointed before physicians; in America the process was 
reversed. 

School nursing may be considered as a development of 
visiting nursing. The latter originated in England about 
1860 and reached America in 1877, when a New York City 
Mission sent the first trained nurse into the homes of the 
poor. Before 1905 the work was sporadic, but since then it 
has gained considerable headway. 

The school nurse, representing a new idea in visiting 
nursing, began work in Liverpool in 1887, when nurses 
paid daily visits to a few schools for the purpose of attending 
to minor injuries and complaints. They also called at the 
homes of children who had more serious ailments and urged 
the parents to obtain the services of a physician. The 
early school nurses were volunteers, and it was not until 
1901 that the London School Board appointed salaried 
municipal school nurses, with definite duties assigned. 
They examined the children for contagious skin diseases and 
excluded all cases found. The nurses did not treat the cases, 
and consulted only occasionally with the school medical 
officer. Later the nurse tested the vision and hearing, and 
kept a record of the physical examinations of the pupils. 



20 MEDICAL INSPECTION OF SCHOOLS 

In 1907 a superintendent, and, recently, assistant superin- 
tendents were appointed. 

The first school medical officer was appointed in London 
in 1891. His duties were to examine absentees from school 
who failed to furnish a doctor's certificate. The following 
year, Dr. Francis Warner published a full report of the 
examination of fifty thousand school children. 

In America, Boston is credited with having established 
the first system of school inspection, in 1894. New York 
had a medical inspector. Dr. Moreau Morse, in 1892, but 
did not establish a system of inspection until 1897. One 
hundred and fifty physicians were appointed that year by 
the Department of Health to inspect the school children. 
These physicians received a salary, of thirty dollars a month, 
and their duties consisted in visiting the schools each 
morning, to examine all children sent them by the teachers 
as suspicious cases of contagious disease. This system was 
in effect until 1902, when the inspectors were required to 
give more time to the work, and the salary was increased 
to one hundred dollars per month. The system was then 
elaborated to include a routine inspection of all children in 
the classrooms for the purpose of detecting cases of con- 
tagious eye and skin diseases. Home visits were made to 
absentees to detect unreported cases of contagious disease. 

The routine inspection of children in the class-rooms 
resulted in the exclusion from school of large numbers with 
cases of minor contagious diseases. It was evident that 
such exclusions had a limited value, and in many instances 
had a harmful effect, as the cases were not considered by 
the parents of sufficient importance to warrant medical 
treatment. This procedure caused enforced absence from 
school, and not only interfered with the education of the 
children, but often made them habitual truants. 



IN'TRODUCTION 21 

At this time experiments were made with a trained nurse, 
Miss Lina L. Rogers, who volunteered to do the work. The 
result showed not only marked improvement in school 
attendance, but demonstrated that all danger of infection 
could be controlled, and that the children could remain at 
school without danger to themselves or their classmates. 

As a result of this experiment the first staff of municipal 
nurses to be employed in the Unites States was established 
in November, 1902, by the Department of Health of the city 
of New York. In December, 1902, a hospital and dispensary 
for the treatment of contagious eye diseases was established 
by the same department, and in 1905 the medical inspectors 
began complete physical examinations of all school children. 

Notwithstanding these many changes, the results hoped 
for did not materialize. The physicians and nurses succeeded 
in obtaining for treatment only 6 per cent, of the physically 
defective children. The records soon amounted to little 
more than a mere compilation of statistical data, and very 
little to show for the work. This resulted in the organization 
of the Division of Child Hygiene, and a largely increased 
staff of trained nurses. 

Experiments showed the economy and efficiency of placing 
the control of contagious diseases in schools iii the hands of 
the school nurse, leaving the medical inspector free to devote 
his entire time to making physical examinations of the 
children. In January, 1912, this system of medical inspection 
was inaugurated, utilizing the services of seventy-four 
medical inspectors and one hundred and seventy-nine nurses, 
under the supervision of a staff of supervising inspectors and 
supervising nurses. 

In 1901, the author started a daily class-room inspection of 
the school children in Philadelphia, and in 1903 inaugurated 
a system of inspection, utilizing the services of a trained 



22 MEDICAL INSPECTION OF SCHOOLS 

nurse. The success of this work resulted the following year, 
in the organization of a corps of fifty medical inspectors to 
perform the work in the schools and control contagious 
diseases. 

By 1905, fifty-five cities had adopted some form of in- 
spection, and at present there are over five hundred cities 
and towns in the United States, with medical inspection of 
schools. The objects of the work include: 

1. The detection of contagious diseases, thereby protect- 
ing the child and the community. 

2. The detection of physical defects which prevent the 
child from acquiring a full education with the least sacrifice 
to his physical welfare. 

3. To find the capacity of the individual pupil to acquire 
knowledge in accordance with his mental and physical 
status. 

4. To insure the best possible hygienic surroundings for 
the child while he is in school. 

5. To bring a closer relationship between the school and 
the home so as to carry out more successfully the oth^r aims 
of medical inspection and insure treatment for discovered 
defects. 

6. To teach the practice of hygiene and healthful living 
both in school and at home. 



PART I. 
ADMIMSTIUTION. 



GENERAL CONSIDERATIONS. 

Investigation of the work performed in five hundred 
cities of the United States shows variations from completely 
organized, efficient systems, to unorganized and partial 
inspections of the school children. The inspections are 
made by physicians, nurses, and teachers, independently or 
in any combination, and in some instances by physical 
instructors. 

While medical inspection of schools is not necessarily 
most effective when the work is performed by physicians, 
their services are required when a thorough physical ex- 
amination is desired. Nurses, teachers, and other laymen 
may perform a number of the duties, but diagnosis and 
medical judgment can be obtained only from physicians, 
who may be part of the staff or volunteer consultants. 
Volunteer work has rarely proved successful. When some- 
thing is required for nothing, one cannot command, and 
services are rendered at the will and desires of the giver. 
A volunteer often looks for a subsequent reward and if it is 
not forthcoming he stops work. Small cities or towns which 
believe they cannot afford the usual compensation for medi- 
cal services should at least provide a small fee and avoid 
the uncertain services obtained from volunteer work. 



24 ADMINISTRATION 

A careful comparison of results obtained by the various 
methods of conducting examinations shows that the greatest 
benefits are obtained when a preliminary examination is 
made by the teacher or a nurse, all defective or suspicious 
cases are then reexamined by trained physicians, who can 
devote sufficient time to the work without interruptions of 
private practice during school hours. Stated hours must be 
given for complete physical examinations of the children. 
Nurses are needed for the "follow-up" work to urge the 
treatment of defects. 

Supervision.^ — Neighboring towns with a few schools and a 
small number of pupils may have the same inspector, and 
arrange the work so he shall devote one or two days each 
week to examine the children in a district. This physician 
should be under the supervision of the board of health of the 
county. 

In cities where a staff of physicians and nurses are em- 
ployed the administrative responsibility is vested either in 
the board of health or the board of education. In the early 
years of medical inspection, the boards of health had the 
supervision in most of the cities, but at present about three- 
fourths of the cities vest such power in the board of educa- 
tion. As to which is the more desirable is a much mooted 
question. To the author it seems that there is little differ- 
ence provided both of these departments work in harmony. 
The department least dependent upon political activity 
and most successful in obtaining appropriations is the one 
which will achieve the most desirable results. 

Cost of Maintenance. — The cost of maintenance varies with 
the school population, the amount and character of work 
required, and the efficiency of the examiners. The greatest 
expense is in the salaries for the inspectors; printing, sup- 
plies, and minor expenditures are a relatively small item 



GENERAL CONSIDERATIONS 25 

even in large cities. The annual salaries of school doctors 
and school nurses as tabulated by the Department of Child 
Hygiene of the Russell Sage Foundation are as follows : 

No. of cities No. of cities 

where doctors wliere nurses • 

receive salary receive salary 

indicated. indicated. 

No salary 75 21 

$1 00- 100 00 47 

$101 00- 200 00 .50 

$201 00- 300 00 44 2 

$301 00- 400 00 25 

$401 00- 500 00 . . 24 1 

$501 00- 600 00 18 21 

$601 00- 700 00 2 17 

$701 00- 800 00 12 24 

$801 00- 900 00 6 ' 15 

$901 00-1000 00 13 2 

$1001 00-1500 00 18 2 

$1501 00-2500 00 ; 7 

$2501 00-4000 00 . 3 

Fees according to service 19 1 

According to this table the majority of school physicians 
are paid under six hundred dollars per year. The character 
and amount of services rendered are in proportion to the 
salaries paid. A city that pays a small salary and requires 
more than three hours' work each day is apt to have the 
work either slighted or performed by disinterested men 
unskilled in the best professional knowledge. It is more 
advantageous to have a small corps of a high standard of 
efficiency and well paid, than a large one with less efficiency 
and small salaries. It is a mistake to require physicians 
to devote their entire time to the work. Half a day or 
the morning session is sufficient for school inspection, and 
the remainder of the day should be allowed for private 
or hospital practice. Such an arrangement assures more 
ambitious and better trained men. 

Laws on the Medical Inspection of Schools. — ^The move- 
ment providing for medical inspection of schools has re- 



26 ADMINISTRATION 

ceived considerable recognition from the legislatures of 
some States; and at the present time the United States 
Government, through its newly created "Children's 
Bureau," is about to make an exhaustive investigation of 
the subject. 

Three States, Massachusetts, New Jersey, and Colorado, 
have statutes making medical inspections mandatory 
throughout their jurisdiction. In New Jersey the law 
states, "Every Board of Education shall employ a com- 
petent physician . . . every Board of Education 
shall adopt rules for the government of the medical in- 
spectors." 

Four States have laws making inspection compulsory 
in certain cities or districts. Of this group, Pennsylvania, 
through its "School Code," enforces compulsory inspection 
in Philadelphia and Pittsburgh. In Indiana there is a 
most stringent statute, which compels physical examina- 
tions in Indianapolis. This law applies to all public, 
private, and parochial schools, and specifies the tax rate 
for this purpose. In Ohio the cities must and the rural 
districts may perform the work. In New York, the chil- 
dren in most of the large cities are examined. 

Many States, such as Georgia, Kentucky, Louisiana, 
Maryland, Mississippi, Rhode Island, South Carolina, 
and Virginia have no legislation on medical inspection, 
but there are efficient systems of inspection in many of 
the cities in the territory. For example, there are four 
cities in Virginia, five in Georgia, and eight in Rhode 
Island that have efficient systems of school inspection 
without any legislative power for so doing. 

Finally, there is a group taking in California, Connecticut, 
Minnesota, Washington, and the District of Columbia that 
has by legislation permissible examinations. 



GENERAL CONSIDERATIONS 27 

The foregoing shows the absolute lack of any concerted 
action on the part of the States in regard to the medical 
inspection of schools. In one case the law may be so com- 
plete as to specify how frequently examinations shall be 
made; and again, the physical examinations may consist 
of nothing more than the testing of hearing and vision 
by teachers. Nevertheless, what legislation exists at the 
present time represents progress, and although it is not 
absolutely necessary to the adoption of medical inspection 
in schools, it is of great assistance to the work, defines 
the powers and duties of those in charge, and gives official 
recognition which aids in obtaining results. 

The "School Code" of Pennsylvania contains the follow- 
ing provisions for medical inspection of schools: 

12. School Medical Inspectors. 

a. Medical and Sanitary Inspection. 

Section 546. 1, Such medical inspection (annually of 
all the pupils of the public schools) shall be made in the 
presence of the parent or guardian of the pupil, when so 
requested by parent or guardian. — 18 May, 1911, art. 
15, §1501, P. L. 391. 

Section 547. 2, The medical inspectors shall, at least 
once each year, inspect and carefully test and examine all 
pupils in the public schools of their districts, giving special 
attention to defective sight, hearing, or other disabilities 
and defects specified by the (State) commissioner of health 
in his directions for the medical examinations of schools. 
Each medical inspector shall make to the teacher, or, if 
the board of school directors so directs, to the principal 
or district superintendent of schools, a written report 
concerning all pupils found to need medical or surgical 
attention, and giving careful directions concerning the care 
of each pupil who needs special care while in school. The 



28 ADMINISTRATION 

teacher, or the principal, or district superintendent shall 
keep such report until the end of the school year, shall 
carry out as carefully as possible said directions con- 
cerning the special care of pupils while in school, and shall 
promptly send a copy of the medical inspector's report 
upon each child to the parents or guardian thereof.— 18 
May, 1911, art. 15, §1505, P. L. 392. 

Section 548. 3, The medical inspector shall, at least 
once each year, and as early in the school term as possible, 
make a careful examination of all privies, water closets, 
urinals, cellars, the water-supply, and drinking vessels 
and utensils, and shall make such additional examinations 
of the sanitary conditions of the school buildings and 
grounds as he deems necessary, or as the regulations of 
the State department of health, or the rules of the board of 
school directors or of the local board of health require. 
He shall see that the laws of the commonwealth relating 
to the health and sanitation of the public schools and the 
requirements of the local board of health are complied 
with.— 18 May, 1911, art. 15, §1506, P. L. 392. 

Section 549. 4, (The medical inspector) shall promptly 
make such reports to the (State) commissioner of health 
as are required by him or by the regulations of his depart- 
ment, and such reports to the local boards of school 
directors as he deems necessary, or as are required by the 
(State) commissioner of health or by the board of school 
directors. He shall perform such other duties as may be 
required by the health and sanitation laws of this com- 
monwealth or by the board of school directors. — 18 May, 
1911, art. 15, §1507, P. L. 393. 

Section 550. 5, No person having tuberculosis of the 
lungs shall be a pupil, teacher, janitor, or other employee 
in any public school, unless it be a special school carried 



THE MEDICAL INSPECTOR 29 

on under the regulations made for such schools by the 
(State) commissioner of health. — 18 May, 1911, art. 15, 
§1509, P. L. 393. 

Legislation pertaining to the physical examination of 
school children should provide for the inspection of all 
pupils whether in private, parochial, or public schools. 
The examinations should be compulsory and not at the 
option of the school authorities. Likewise teachers and 
janitors should be subjected to physical examinations. 

To avoid friction between the educational and health 
authorities, the statute should specify which department 
is to assume responsibility for both maintenance and 
administration. For the guidance of the administrative 
officers the duties of the inspectors should be clearly set 
forth and provision made for the enforcement of certain 
recommendations of the examiners. To cover cases where 
it is impossible to persuade parents to obtain treatment 
for physical defects which hinder the education of the 
child, some penal provision should be ijiade to insure 
the proper execution of any law imposing a duty upon 
the people. 

If there are no public health laws which authorize the ex- 
clusion from school for the failure to receive a vaccination 
against smallpox, or where a communicable disease exists, 
such' provisions should be made in legislation on school 
inspections. 

THE MEDICAL INSPECTOR. 

Systems of medical inspection which have for their 
object not only the detection of cases of contagious diseases 
but also the diagnosis of physical defects, require trained 
physicians as inspectors. Some cities and towns conduct 
the examinations of pupils without the immediate service 



30 ADMINISTRATION 

of a physician. In such cases the work is performed by 
teachers or nurses, but their diagnosis is, or should be, 
submitted to a physician for confirmation. These teachers 
or nurses should not be called medical inspectors. They 
are valuable accessories to medical inspection, and each 
have their place. They may perform equally as well such 
duties as testing of vision or hearing, but there are few 
other defects which they can diagnosticate with certainty and 
safety. School inspections frequently require medical 
services, and these cannot be rendered by a teacher or a 
nurse. They are not graduates of a reputable medical 
school and licensed by the State to practise medicine in 
all its branches, therefore they are not legally qualified 
to perform medical duties. 

In towns where it is impossible to command the services 
of a physician, the teacher or a nurse may act in the 
capacity of examiner and refer suspicious cases to a phy- 
sician who may volunteer his services. 

Number of Inspectors Required. — One medical inspector to 
every five thousand pupils is a fair average in estimating 
the number of physicians required for the work in a city. 
This figure will vary with the amount of work to be done; 
depending on the number of pupils in a school, the distance 
between the buildings, the character of the population, the 
probable number of defects found, and the system of in- 
spection employed. Where the schools are situated, in 
suburban or outlying sections, several miles apart, an 
inspector should take a smaller number of pupils, as much 
time is lost travelling between the schools. In a congested 
section of the city with schools close together, he can spend 
more time in actual work. Among the foreign population 
a greater number of defects exist, and more time is 
required to have recommendations carried out. On the 



THE MEDICAL INSPECTOR 31 

other hand, if .the children are American born, parents 
generally attend to their physical needs promptly, re- 
quiring less effort on the part of the medical inspector. 
The school population that should be assigned to one 
inspector also varies with the number of duties and the 
system of inspection employed. A system overloaded with 
clerical work decreases the probable number of pupils that 
can be efficiently cared for. 

Qualifications and Training of Inspectors. — Any competent, 
conscientious physician may be trained for the position 
of medical inspector. The great number of applicants 
for these positions makes it difficult at times to choose. 
The "merit system," or civil service examination, which 
eliminates favoritism and political interference, has solved 
the problem in those cities where such methods are adopted. 
Where practical questions pertaining to duties of the posi- 
tion have been asked, and due allowance made for previous 
training, the civil service method has been successful. 

The appointment of physicians as school inspectors, 
where civil service examinations and rules are not ob- 
served, should require much thought by the appointing 
powers. The personality of the doctor, his previous train- 
ing, his interest and enthusiasm in the work, are all worthy 
of consideration. It is desirable to have a physician who 
has had previous training in the diagnosis of contagious 
and skin diseases, and practical knowledge of some of the 
specialties, particularly the eye, ear, nose, and throat. 
Internes from hospitals for contagious diseases receive 
valuable training for this work. Previous experience in 
some social work, giving an idea of the relation of home 
conditions to physical defects, serves the inspector in a 
number of ways, and should be considered in making an 
appointment. The University of Pennsylvania offers a 



32 ADMINISTRATION 

special course to those desiring to apply for such positions. 
It is unfortunate that more of the medical colleges do not 
offer special courses to train physicians in this new post- 
graduate work. In the author's opinion, if the remunera- 
tion to medical inspectors was larger, more men would 
take special courses to better qualify for the positions. 
That there are methods of training a corps of physicians 
after appointment is true, but the time which can be spared 
for such instruction is limited. Such after-training may 
consist in personal instruction at the contagious disease 
hospital and lectures on skin diseases and the other special- 
ties by experts. Instructions on the practical work in the 
schools may be given by supervisors or trained inspectors. 

Duties of Inspectors. — The physician should visit daily 
all the schools assigned to him. He should examine the 
children sent by the teachers for suspicious signs of con- 
tagion. Accuracy in diagnosis is necessary to prevent 
epidemics. When a contagious disease exists in a school, 
every precaution must be taken to prevent the occurrence 
of other cases. 

The medical examiner should not only diagnose physical 
defects which may handicap a child in its schooling, but 
also try every conceivable means to have such defects 
corrected. The glaring defects may be called to the phy- 
sician's notice by a teacher, but the greater number must 
be found by a thorough systematic physical examination 
of each child. 

The responsibility of the school physician for the health- 
ful living of the children at school and at home is of im- 
portance. He should recognize unsanitary and unhealthful 
conditions at school, which may cause illness, and aid the 
teacher in her instructions on hygiene, thereby directing the 
children in proper living at home. 



THE MEDICAL INSPECTOR 33 

Investigations and reports from various cities often 
estimate the amount of work performed by medical in- 
spectors by the number of pupils examined and number of 
hours spent in doing the work. These are poor criterions. 
Quantity is a minor consideration compared with quality, 
which is measured by results obtained, especially in the 
correction of defects found. The work performed naturally 
varies with the capabilities of the inspectors. Some are 
quick and accurate in diagnosis, interested and persistent, 
and at the same time tactful in recommendations to parents, 
thus achieving results. Others fail to recognize important 
physical defects and even contagion. Furthermore, they 
may be disinterested and fail to obtain results from recom- 
mendations. Due allowance must be made for the character 
of school population. Most of the foreign element take 
kindly to recommendations for treatment, provided the 
inspector aids them in obtaining the necessary medical 
assistance. Some parents, however, resent being told that 
their children have certain defects, and object strongly when 
urged to seek advice. Many of these cases are converted 
by tactful consultations between physician and parent. 

Equipment of Medical Inspectors.— The equipment needed 
for the medical examiner depends on the duties he is to 
perform and whether they include the supervision of con- 
tagious diseases in the homes. If he enters infected houses 
he should carry a leather bag containing a gown of rubber 
or white duck, a cap, pair of rubbers, lysol or bichloride 
of mercury tablets for disinfection of hands, rubber gloves, 
syringe for administering antitoxin, placards and literature 
issued by the health department for instruction of families. 
The contents of the bag can be constantly disinfected by 
adding to the equipment a tin box with perforated lid con- 
taining gauze kept wet with formalin. 
3 



34 ADMINISTRATION 

An ample supply of blanks and cards for recording the 
work performed should be carried or kept at the schools. 
Few cities allow the medical examiners to undress children 
for thorough physical examinations, and he must, therefore, 
depend more upon subjective signs and symptoms than 
upon the use of instruments of precision to diagnose defects. 
A stethoscope is occasionally required for examinations of 
the chest. Culture outfits for the laboratory diagnosis of 
diphtheria are frequently required. 

Vaccine virus and diphtheria antitoxin should not be 
carried by the inspector unless for immediate use. Virus and 
antitoxin not kept on ice rapidly deteriorates and becomes 
inert. 

In each school there should be a room set aside for the 
inspector and nurse in which examinations can be made. 
This room should be well lighted and if possible at least 
twenty feet long, to admit of examination of vision. 

Several test cards should be placed on the wall in a good 
natural or artificial light. Running water at a sink or 
wash bowl is necessary. A small medicine closet should 
be equipped with such supplies as may be required for 
emergency — bandages, cotton, adhesive plaster, collodion, 
bichloride tablets, aromatic spirits of ammonia, alcohol, 
and a number of wooden tongue depressors. The latter 
are inexpensive, and can be thrown away after an examina- 
tion, a distinct advantage over a metal depressor carried 
by the inspector. Toothpicks or wooden applicators are 
handy for many purposes. This same closet may contain 
the equipment necessary for the nurse, such as ointments 
and lotions. All poisons should be kept separate and in 
colored bottles plainly labeled "poison." This closet 
should always be kept locked, and when not in use the 
key kept in the ofiice of the principal. A supply of record 



DIRECTOR AND SUPERVISORS 35 

blanks and literature for instruction should be in each 
school. 

Additional Work during Summer. — Where medical inspec- 
tors are under the supervision of the health department, 
and paid for twelve months' work, they can be utilized 
during the summer months in campaigns to reduce the 
mortality among infants. They can supplement the in- 
spectors engaged on contagious diseases, and if smallpox 
is prevalent, they can constitute a special vaccinating 
corps. Philadelphia uses their services to fill absences 
during summer vacations. Where the examiners are em- 
ployed by the Board of Education, they should be subject 
to the same rules as teachers, and allowed the summer 
months free. 



DIRECTOR AND SUPERVISORS. 

Qualifications and Training.^ — In cities employing a large 
number of inspectors, it is necessary to have a director, or 
chief of the division, and, if numbers warrant, one or more 
assistants or supervisors. A supervisor can manage ten 
to fifteen medical inspectors. The director is responsible 
to the Superintendent of Schools or the head of the Health 
Department. His duties are to superintend the work of all 
the inspectors. If supervisors or assistants are employed, 
they are responsible to the chief or director for the work 
performed by the men under them. The success of the 
department is largely dependent upon the efficiency of the 
director. He must have executive ability combined with a 
thorough knowledge of the subject of medical inspection. 
He should know the sections of the city in relation to social 
conditions. A man of education and refinement, coupled 



36 ADMINISTRATION 

with a pleasing personality, is one much desired. Tact 
and diplomacy will serve him well on many occasions. 
Resourcefulness, friendliness, and firmness, coupled with 
gentleness, are traits of value. He should be a good teacher 
and disciplinarian, capable of directing wisely. His strength, 
energy, and judgment should not be dissipated on small 
details and minor duties, which can be cared for by others 
whose time is less valuable. 

The only previous training which will prepare a physican 
for the position of director is former service as a medical 
inspector and experience in some executive position which 
entailed his managing others. The same qualifications 
are required for his supervisors or assistants. 

Duties. — The director must outline a practical system of 
inspection suited for his city. The system must be simple 
and not burdened with unnecessary clerical work. He 
has under his care a number of men with varying ability 
and personalities, and it is his duty to, organize his corps 
that there shall exist uniformity in the work. The physician 
who has formerly specialized on the eye, must be watched 
that he does not report only eye defects; the nose and 
throat specialist must be discouraged from devoting too 
much attention to these organs, and so on with all the 
specialists. However, it is well where another inspector is 
in doubt, to utilize the knowledge of those men in the 
department who are experts on the subject. The director 
does well to gain the admiration and respect of his men by 
kindness and thoughtfulness. When one man has failed to 
do a thing properly, the individual should receive censure 
rather than the department. Respect the opinions and 
welcome suggestions from the inspectors. 

It is necessary for the chief to make occasional visits to 
the schools to watch the character of the work performed 



DIRECTOR AND SUPERVISORS 37 

and to lend encouragement. These visits do not always 
show the true quality of an inspector's work, for he may 
put forward an extra effort for the occasion. Questioning 
the principals of schools as to the quality of the work is 
also bad policy and avails nothing. Few inspectors fail 
to stand well with the principals, and such questioning 
only leads the school authorities to doubt the efficiency of 
their visiting physician. When necessary, tactful investi- 
gations can be made without the knowledge of principal 
or doctor. The requisities which are set down for the chief 
also apply to his assistants. 

Executive Ability and Office Control.^ — ^The chief sources 
of information which the head of the department has at 
his command, as to the work performed by each one under 
him, are the reports of his supervisors and the daily reports 
of each inspector. This shows how necessary it is to have 
a system that is simple and practical and not overloaded 
with numerous forms. The daily reports should tell him 
almost at a glance where something is going wrong. It 
is impossible for a chief to inspect the work of each man 
each day. He must depend on those under him, and if he 
is fortunate enough to have confidence in the work of a 
subordinate, it is well to show this trust. Encouragement 
and interest in the work can be given to the medical in- 
spectors by occasionally calling on them to perform some 
special work which they may be individually interested 
in, and from which the department can benefit. A custom 
of going elsewhere for advice and suggestions regarding 
work which can equally as well be obtained from the em- 
ployees of the department is poor policy. It disheartens 
the members of a corps, and tends toward routine and 
monotonous work that is detrimental. 

Many of the present systems of medical inspection have 



38 ADMINISTRATION 

a great variety of forms which add to the clerical work 
and detract from the practical results. These systems, with 
their large number of blank reports, are subject to frequent 
changes by revision and additions, which tend to make 
confusion in the department. A glance in the office closets 
and store-rooms for discarded forms and literature is an 
index of efficiency. While simplicity and practicability 
should be the essential features in designing recording 
blanks, allowance must be made for gathering statistics 
of value. Good statistics based on actual work are necessary 
for the adjustment of activities. 



BUREAUS OF CHILD HYGIENE. 

Five cities in the United States have a Bureau of Child 
Hygiene as a part of their health department, and in three 
of these cities medical inspection of schools is one of the 
functions of the bureau. The work includes everything 
which pertains to the child from birth, and even prenatal 
conditions, until the child reaches the working age. Factors 
for the reduction of infant mortality, including supervision 
over midwives, maternities, baby farms, day nurseries and 
foundling institutions, are important features of the work. 
Medical inspection of schools and the enforcement of laws 
relating to child labor, including the issuing of employ- 
ment certificates, are performed by the same inspectors or 
a separate corps under the supervision of this bureau. 

In Philadelphia the Division of Child Hygiene includes 
the care of the child to the time of entering school, and 
public school inspection is under the supervision of the 
Board of Education. 

Philadelphia employs fifty medical inspectors, one chief 



BUREAUS OF CHILD HYGIENE 



39 



of school medical inspection, and five supervisors. Each 
supervisor has a district or part of the city arranged accord- 
ing to school population, and in charge of ten inspectors. 
The school population is about 200,000. These inspectors 
are under the Board of Education, and are employed only 
in the public schools. 

Fig. 1 




Filing records at the central office in the health department. 



As the '"School Code" failed to arrange for the inspection 
of the parochial schools, the Bureau of Health assigned 
these schools to the contagious disease inspectors in charge 
of the wards where such schools are located. This work is 
supervised by the assistant chief medical inspector. 

Chicago has school inspection as a part of its Child 



40 ADMINISTRATION 

Hygiene Bureau, and for its 400,000 pupils in both public 
and parochial schools employs one hundred medical health 
officers or inspectors and forty-one nurses. For adminis- 
tration purposes, five of these medical health officers are 
selected to supervise the other ninety-five without extra 
pay. Two of the nurses supervise the other thirty-eight. 
The city is divided into ninety-five districts, to each of 
which is assigned a medical officer. 

New York City has a Division of Child Hygiene under 
the supervision of a director, who is responsible to the 
sanitary superintendent. The staff of the division for 
school inspection includes seventy-four medical inspectors, 
one hundred and seventy-nine nurses, and seventeen clerks. 
The nursing staff is directed by a superintendent of nurses, 
who is responsible to the chief of the division. In each 
borough there are one or more supervising nurses to superin- 
tend the work of the nurses detailed to that borough. 

The functions of the division are educational and ad- 
ministrative. Its educational functions consist in teaching 
parents, particularly mothers, in the care of infants and 
children, and in the need of timely prevention and treat- 
ment of physical defects. 

Its administrative functions include: 

1. The medical inspection of school children to detect 
the presence of contagious diseases, and the examination 
of the children to determine the presence of physical 
defects. 

2. The enforcement of such laws of the State, such pro- 
visions of the "Sanitary Code," and such other regulations 
of the Board of Health as bear directly on the protection 
of the health of children of the community. 

3. The supervision and regulation of the practice of 
midwives in the city of New York. 



BUREAUS OF CHILD HYGIENE 41 

4. Through permits, the regulation of the conditions 
under which children are boarded out and the supervision 
of women engaged in the care of children. 

5. The supervision of institutions harboring children 
and of day nurseries. 

6. The issuance of employment certificates to children 
who have complied with the provisions of the child labor 
law, for the ' purpose of preventing the employment in 
factories or in mercantile establishments of children who 
are physically unfit to be so employed. 

Organization. 

The division forms a part of the sanitary bureau of the 
department. The budget appropriations for the work have 
been as follows: 

1909 1910 1911 1912 

$335,370 $348,190 $386,390 $554,095 

The staff consists of: 

152 medical inspectors (physicians). 

263 trained nurses (who must have registered with the 

Board of Regents of the State of New York) . 
55 nurses' assistants. 
23 cleaners. 
31 clerks and typists. 
All employees are included in the civil service classification. 
In addition, the following temporary employees are 
assigned for the extra duties of the infants' milk stations 
from May 1 to October 1 : 
55 trained nurses. 
55 nurses' assistants. 
The organization proper consists of: 



42 ADMINISTRATION 



Central Organization. 



Director of Child Hygiene. 

(Who is the administrative officer of the division, in 

charge of the work throughout the entire city, and is 

directly responsible to the Sanitary Superintendent.) 
Assistant Director. 

Supervising Inspector of Infants' Milk Stations. 
Superintendent of Nurses. 
Clerks and Typists. 
Borough Chief, in each borough. 

(Directly responsible to the director, and in charge 

of the indicated borough.) 
Supervising Inspectors. 

(Each in charge of a squad of from ten to fifteen 

inspectors and under the direct supervision of the 

Borough Chief.) 
Supervising Nurses. 

(Each in charge of a squad of from fifteen to twenty 

nurses, and directly responsible to the Supervising 

Inspectors.) 
Medical Inspectors. 
Nurses. 

Nurses' Assistants. 
Cleaners. 
Clerks and Typists. 



SCHOOL NURSE. 

In many cities where physicians were employed to per- 
form the school inspections, innumerable defects were 
recorded, but only a small percentage received treatment. 



SCHOOL NURSE ' '43 

This was due to indifference or ignorance on the part of 
parents, who did not realize the importance of the recom- 
mendations, and to the inabihty of the physician to spare 
the time to personally explain to them the dangers of 
certain diseases. It was evident that some connecting link 
was necessary between the doctor and the parents, the 
school, and the home. The school nurse has filled this gap 
in medical inspection. 

In the early days of school inspection, the duty of the 
physician was to detect contagious diseases and exclude 
all such cases. No distinction was made between the 
major infections, such as scarlet fever and diphtheria, and 
the minor contagious skin diseases, impetigo and ringworm. 
Children afHicted with any disease known to the medical 
profession as contagious or communicable were excluded 
until cured, and often remained from school longer than 
the illness warranted, due to failure to obtain medical 
advice and treatment. Many pupils were thus deprived 
from schooling when a few treatments at school would 
have made it safe for them to remain in the class-room. 
The system not only deprived the child of valuable hours 
of teaching, but tended to make truants of those with a 
weakness in that direction. 

With the progress of school inspection came the ex- 
amination for physical defects which might interfere with 
the progress of the child. Many defects were found and 
many written recommendations were sent to parents, only 
to receive scant attention. Although records and reports 
were plentiful, results were not forthcoming. 

Poverty, indifference, and ignorance were causes assigned 
for the failure to obtain treatment for the defects found 
by the school physicians. It was evident to those in 
authority that to obtain results some auxiliary to school 



44 ADMINISTRATION 

inspection was needed. The trained school nurse with her 
"follow-up" system was the solution of the problem. Her 
work has steadily grown, and become systematized, and 
today it is conceded that school nursing is one of the most 
important parts of the work of medical inspection. The 
thousands of cases in the care of nurses can be accurately 
determined, but there is no way to estimate the benefits 
to the school and the child, the suffering alleviated, the 
number of children brought to a condition in which they 
receive the full benefits of school instruction, or the number 
of lives saved 

Number Required and Appointment. — Most school physi- 
cians are employed to perform a certain amount of work, 
and while in some cities a specified number of hours is 
assigned, rarely the entire working day is required. School 
nurses, on the other hand, must work the entire day and 
six days per week. The working day includes the five 
school hours, some of the noon recess, and also time after 
school. The greater amount of time allotted to her work 
permits a nurse to attend a greater number of pupils than 
the school doctor. Eight thousand pupils is a fair average 
to apportion to one nurse. This number of pupils will 
require her entire time, and will not permit any outside 
or additional work, such as teaching mothers the care of 
infants or supervising milk depots. In cities where nurses 
must perform other duties, it is advisable to assign a 
nurse to each inspector or one to a district. 

The appointment of nurses depends upon which munici- 
pal department has control of school inspection. If a city 
employs only a few nurses, paid by the educational author- 
ities, the selection may be made by the superintendent 
of schools, the board of education, or its committee on 
elementary schools. Where the health department has the 



SCHOOL NURSE 45 

supervision, the appointment is made by the director or 
the health officer. It is inadvisable to have the supervision 
of nurses and of physicians under different departments, 
as it admits of lack of cooperation and probable friction. 

In cities employing a large corps of nurses, and where 
not specified by law, considerable annoyance and responsi- 
bility can be saved for the appointing power by utilizing 
eligible lists from civil service examinations. To obtain 
the most efficient help through such examinations, the 
questions must be practical and pertaining to the duties 
of the position. The averages, however, must not be based 
solely on the answers; due credit should be given for previous 
experience and training, as well as for judgment, tact, and 
personality judged by personal interviews. 

Where civil service lists are not used, the person who 
makes the appointments may profit by considering the 
opinions of the chief or supervisor who is directly respon- 
sible for the work of the department. 

When more than five nurses are employed, it is advisable 
to have a supervising nurse who should outline and superin- 
tend the work. She should be responsible for those under 
her and report to the chief inspector, and should preferably 
have served as a school nurse. 

Qualifications. — A school nurse should be a graduate of 
a reputable training school and should have had one or 
two years of private work. Experience gained in visiting 
nursing is also of great advantage. Preference should be 
shown the nurse who seems to be interested in work of 
this character. School nursing requires gentleness, yet 
firmness, tactj perseverence, and resourcefulness. An 
efficient nurse is willing to be supervised and does not 
oppose criticism of her work. This quality is acquired by 
a good hospital training. The character and temperament 



46 ADMINISTRATION 

of the applicant as well as her physical health should 
receive serious consideration. A thorough physical ex- 
amination should be required of all applicants for the 
position and cases eliminated where ill health is likely to 
result in repeated absence from work. 

A knowledge of a foreign language, especially Italian, 
Russian, or German, greatly aids in obtaining results among 
foreigners. Conversing in their native language wins the 
confidence of parents unable to speak or understand English, 
and is a distinct advantage over the use of an interpreter. 

One occasionally meets a nurse who adversely criticises 
the work of the physician or the teacher. This unfortunate 
trait or acquired habit, creates disloyalty and antagonism. 
While this ■ assertion may seem unnecessary, the author 
knows of several instances in which such actions have been 
the undoing of an otherwise efficient nurse. 

Duties of School Nurses. — Where a nurse conducts the 
medical inspection in lieu of a doctor, she examines the 
vision and hearing of the pupils, recognizes signs and symp- 
toms suspicious of contagion or physical defects, and refers 
the cases to a dispensary or physician for confirmation 
of her diagnosis. Upon the recommendations of physicians 
she urges parents to have defects treated. She also combats 
uncleanliness and aids n the teaching of hygiene. 

Nurses working in conjunction with physicians in school 
inspection are assistants to the physicians, aiding them in 
the physical examinations and procuring treatment for 
defects found. In class examinations, with the assistance of 
the teachers, she designates the pupils who should receive 
an early inspection by the physician. 

After diagnosis the nurse takes full charge of the case 
and uses all available methods to have the parents obtain 
treatment. By home visits and school consultations she 



SCHOOL NURSE 47 

establishes a better understanding and closer cooperation 
between the school and the home. 

The function of the school nurse acting in the capacity 
of a social educator on public hygiene is of great importance. 

Equipment of Nurses. — ^The school nurse should wear a 
regulation outfit, one which will at all times distinguish her 
in her work. A neat, plain, dark blue or gray dress made of 
linen, chambrey, or of ' other washable material is best. 
This uniform is of equal value, and serves the same purpose 
as a badge, assuring her entrance to the homes. She 
becomes known by her uniform, which even affords her 
protection when working in the tenderloin districts. 

Nurses in uniform have gone with perfect immunity in 
neighborhoods where men would fear to enter. Here they 
have not only been welcomed, but notorious characters 
have led them to residences they were seeking. 

In a few cities a special bag is provided for the nurses. 
These bags should not be too cumbersome, but large enough 
to hold a few drug supplies, instruments, aad record cards. 
She should have a clinical thermometer, bandage, scissors, 
wooden tongue depressors, and applicators or toothpicks, 
medicine or eye-droppers, absorbent cotton, adhesive 
plaster, and safety pins. A few drugs should be carried in 
the bag, including aromatic spirits of ammonia, alcohol, 
tincture of iodine, tincture of green soap, bichloride of 
mercury tablets, and lysol. 

Drugs should be placed in one- or two-ounce vials and 
plainly labelled. All poisons should bear a conspicuous 
"poison" label. Cotton, bandages, and gauze should be 
kept in a tin box. These bags should be frequently in- 
spected for cleanliness and replenishing. Where there is a 
supervising nurse, inspections of outfits should be made 
at regular intervals. 



48 ADMINISTRATION 

At each school the nurse should have a closet in which 
to keep supplies, record cards, and literature. These closets 
should contain the things described under the medical 
inspector's outfit. 

Methods of Work. — The work of the school nurse is per- 
formed in the schools, at homes, and in dispensaries. She 
should visit daily every school under her care, beginning 
with the first school soon after the opening exercises. In her 
box containing the record cards there should be two sep- 
arate compartments, (l) containing new cases, and (2) cases 
under treatment. The nurse should go to the principal's 
office, announcing her presence and receive the cards of 
patients referred to her by the physician at his previous 
visit. She should then send for these children, taking 
usually one, but not more than two or three from the class- 
room at a time, and treat or instruct each case in a room 
set aside for her work. When finished with a child, another 
case is sent for, using the child just leaving as a messenger, 
and so proceed until all the new cases are disposed of. 
Then the cases under treatment that need attention that 
day are sent for. The same system in sending for the children 
applies with these cases, and the work should be planned so 
as to finish with the pupils of one class-room before taking 
up the next. This creates less confusion and annoyance to 
the teachers. 

If a child is to receive instruction regarding uncleanliness 
of head or body, such instruction should not be given before 
another child, unless there are a number of pupils requiring 
the same instructions. When preparing a printed circular 
of instructions to be carried home to parents, the nurse 
should fold the circular and place in an envelope, thereby 
respecting the feelings of the child. 



SCHOOL NURSE 49 

If a parent's attention is to be called to an existing defect, 
one of the following cards should be used. 

Department of Public Health and Charities. 

BUREAU OF health. 

Division of School Inspection, Room 712, City Hall. 



Mr 

Dear Sir: — ^This is to notify you that 

, a pupil in the 

...School, is in need of medical attention 

for 

You are advised to consult a physician, 

hospital, or dispensary without delay. 

Very truly yours, 

Philadelphia, . 19 :. 

Medical Inspector. 

There is no advantage in having separate notification 
blanks for the various defects. If this simple form does 
not arouse the interest of a parent to the point of action, 
other steps must be taken. 

Before resorting to a visit to the home, the nurse should 
send by the child a request for the parent to come to the 
school. These visits are termed "school consultations." 
A parent may be notified to call at the school in the interest 
of the child, and a time set which is convenient to the nurse, 
by using the following form. The card should not specify 
any particular disease, and should be signed by or with 
the name of the principal of the school. A request from 
4 



50 ADMINISTRATION 

the principal will bring a quicker response than from the 
physician or nurse. 

...School District; No 191-. 

Mrs 



Dear Madam: — Your child, , has been found 

by the medical inspector to be suffering from defects which 

his 
greatly interfere with , work at school. 

Kindly call at the school on ...at ..o'clock, 

in order that we may explain to you what can be done to 

help , . ' 
him. 

This is very Important. 

Principal. 

At school consultations, the nurse should be tactful in 
her manner of informing parents of the existence of certain 
defects in the child. Little is accomplished by exaggerating 
the dangers from an unattended disease : it not only frightens 
the parent, but if the physician to whom the child is event- 
ually taken belittles the physical ailment, the parent loses 
confidence in the nurse and school inspector. Instead of 
saying a child is backward due to a physical defect, the nurse 
should emphasize the fact that the child may learn more 
readily and with less exertion if the defect were corrected. 
Most parents resent being told that their children are men- 
tally dull. It is also advisable not to use medical and other 
scientific terms in explaining the illness of the child. Such 
terms are not generally understood by the public, and, by 
confusing them, tend to defeat the purposes of the con- 
sultation. The nurse should avoid arguments regarding 



SCHOOL NURSE 51 

a diagnosis, as these also tend to jeopardize any favorable 
impressions that may have been made. If the parent 
seems refractory and unwilling to act upon suggestions, 
the teacher or principal may be called upon to aid in 
accomplishing the object of the visit. 

Should the parent neglect to call at the appointed time, 
the nurse should not censure the child or send threatening 
communications to its home. The proper way is to learn 
the reason for the parent's absence. If it is the child's 
mother, she may have been detained by the care of an infant 
or other home duties, or the time appointed may have been 
inconvenient. If the child's excuse for the parent warrants, 
list the case for a visit to the home. There are few cases, 
where the parent calls at the school to inquire what is 
desired, which fail to receive prompt attention. 

A parent may be willing to have the child treated, but 
pleads lack of funds to pay for services and lack of time to 
spend at dispensaries. In such cases the nurse should offer 
her services and request the parent to sign a card granting 
her permission to obtain any necessary treatment. The 
accompanying blank is for this purpose: 

-__191 

To the Principal, 

_. _... School: 

I hereby authorize the School Nurse to take my child 

to an institution to have , . physical defects properly treated. 



Parent's Signature. 
Residence. 



52 



ADMINISTRATION 



This authorization in writing relieves the nurse from any 
responsibility or blame for proceeding to have the child 



Fig. 2 




Nurse's outfit in school. 



treated, and protects her in case a parent should deny 
having given permission. 



SCHOOL NURSE 53 

Even with one of these permits properly signed, the nurse 
should never consent to a serious operation at a hospital 
without again consulting and obtaining the written consent 
of the parent. 

The nurse should always encourage the consultation 
with the regular physician of the family, and only upon 
evidence of poverty should dispensaries or school clinics 
be advised. Parents desiring to avail themselves of the 
services of a dispensary should be told by the nurse the 
location of the nearest one and the clinic hours for the dis- 
ease to be treated. She should arrange one or two after- 
noons each week to take cases to the dispensaries and 
school clinics. 

After disposing of all the old and new cases, and time 
permits, the nurse may make a preliminary inspection of 
the pupils in one or more class-rooms. Where there is no 
physician to perform class-room inspections, the nurse may 
utilize these opportunities to discover children with physical 
defects, but where her work supplements that of the phy- 
sician, she should select a class not recently examined by 
the physician and adopt the following procedure: Without 
.disturbing the exercises she should walk slowly up and down 
each aisle, observing each child for cleanliness or eruptions 
on skin, suspicious of contagion. Having noted the names 
,of the children, those requiring immediate attention are 
sent for and the others are called at the next visit. 

The nurse should divide her morning hours so as to allow 
a stated period of time to each school. When one of these 
periods is completed she should proceed to the next school 
on her route and perform the work in the manner outlined 
above. 

A certain number of visits to homes are needed to make 



54 ADMINISTRA TION 

the work effective. These visits are made after school 
hours and on Saturdays, unless there are many visits, when 
part of the afternoon session can be used for this purpose. 
At the homes the nurse should observe the building and 
social conditions, and should suggest remedies for unsanitary 
conditions where needed. In this way the nurse becomes 
the social visitor and should acquaint herself, where possible, 
with existing poverty. She should be able to decide when a 
case is worthy of free medical services, also when glasses 
should be furnished free by the city. It is necessary at 
times to devise ways and means for obtaining a brace, a 
high shoe, or other appliances to correct a deformity. In 
order to be of most help in such cases, the nurse should know 
all of the charity agencies and what functions they perform. 
Cooperation with available organizations is a great aid in 
the work. 

It is impossible to give the details of procedure for each 
of the many circumstances that may arise, but a resourceful 
nurse always finds the remedy. The experiences of most 
school nurses have shown that opposition is the exception, 
not the rule. 

To gain the confidence and friendship of the mothers is 
the key to success, and many seemingly hopeless cases have 
yielded to persuasion and kindness. 

The following cases are not treated at school, and should 
be excluded: 

1. Contagious eye diseases with symptoms of acute 
inflammation or discharge. 

2. Contagious skin diseases with extensive lesions. 

3. Pediculosis with live pediculi. 

The following cases are allowed to attend school while 
under treatment by a private physician, dispensary, or school 
nurse : 



SCHOOL NURSE 55 

1. Acute conjunctivitis. 

2. Pediculosis with nits but no 1 ve pediculi. 

3. Skin diseases including ringworm of scalp, face, or 
body; scabies (if gloves are worn); impetigo and avus. 

4 Trachoma if there exists no acute nflammation or 
discharge, and the case is under constant treatment Cases 
of trachoma should not be treated at school. 

The nurse should adopt the following methods of treat- 
ment at school: 

Pediculosis: The child is given a circular containing 
printed instructions, and he is to report to the nurse on the 
following day, when she can readily see if the instruction? 
were carried out. 

Instructions to Parents on the Care of Children's 
Hair and Scalp. 

Children affected with vermin of the head are excluded 
from school. The following directions will cure the con- 
dition: 

Mix one-half pint of sweet oil and one-half pint of kerosene 
oil. Shake the mixture well and saturate the hair with the 
mixture. 

Then wrap the head in a large bath towel or rubber cap 
so that the head is entirely covered; the head must remain 
covered from six to eight hours. 

(Tincture of larkspur may be used instead of oil mixture. 
The directions for use are the same.) 

After removing the towel, the head should be shampooed 
as follows: 

To two quarts of warm water add one teaspoonful of 
sodium carbonate. Wet the hair with this solution and 
then apply castile soap and rub the head thoroughly about 



56 ADMINISTRATION 

ten minutes. Wash the soap out of the hair with repeated 
washing of clear warm water. Dry the hair thoroughly. 

Nits: If the head is shampooed regularly each week, 
as above described, it will cure and prevent the condition 
of nits. 

Impetigo: Remove crusts and clean parts with tincture 
of green soap and apply ammoniated mercury ointment or 
an ointment of zinc oxide. 

Ringworm of face or body: Clean with tincture of green 
soap and apply collodion. 

Ringworm of scalp: Clean with tincture of green soap 
and apply an ointment containing tar. 

Conjunctivitis: Instillations of a solution of boric acid — 
ten grains to one ounce of distilled water. If there is any 
mucopurulent discharge instil one drop of a twenty-five per 
cent, argyrol solution. 

Blepharitis: Rub on eyelashes an ointment of yellow 
oxide of mercury, two grains to one ounce. 

Scabies: Should not be treated at school, but parents 
should be shown how to properly apply sulphur ointment. 
Three applications on successive nights at bedtime is suffi- 
cient. All clothing and bedclothing must be thoroughly 
boiled to prevent reinfection. 

Wounds: Thoroughly cleansed with a bichloride or other 
antiseptic solution and a dry sterile dressing applied. 

Emergency cases should be treated as the occasion requires, 
and if serious the child should immediately be sent home. 
Vomiting should suspicion scarlet fever or other infection. 
All cases suspicious of contagion (acute infectious diseases) 
should be immediately reported to the inspector of con- 
tagious diseases. 

The Value of School Nurses. — The need of trained nurses 
for school inspection has become apparent in most cities 



SCHOOL NURSE 57 

where physicians alone are employed. Records and sta- 
tistics, wherever the system has been tried, show the effec- 
tiveness of the nurse in obtaining treatments and results. 
It has proved vastly superior to the many methods in use 
previous to the employment of school nurses, and has brought 
about a spirit of cooperation on the part of parents, much 
more effectively than the old practice of written notices 
and exclusions. Conflict and misunderstanding between the 
physician, school, and home has been replaced by confidence. 

Repeated suggestions have been made to enact a law 
which would provide a penalty for failure of a parent to 
obtain necessary treatment upon the recommendation of the 
school physician. However, should such laws be enacted, 
it is questionable whether they would not be declared 
unconstitutional. Where an efficient system of school 
nurses has been established, the results will be equivalent 
to those which could be expected under possible legislative 
enactment. History proves that laws are not the "cure- 
alls" to all shortcomings and needs, and less faith should 
be placed in their action. This is not surprising, for often 
persuasion and reasoning succeed in accomplishing things 
which the laws cannot. In the author's opinion, any legis- 
lature which will make it mandatory for cities to employ 
both physicians and nurses for the schools, will save itself 
the need of any further legislation on this and many other 
subjects pertaining to public health. 

The following information gathered by the Department 
of Child Hygiene of the Russell Sage Foundation of New 
York is as interesting as it is disappointing. 



58 ADMINISTRATION 



Cities Employing School Nurses and Number op 
Nurses Employed. 

No. of cities No. of 

Division. having nurses. nurses. 

North Atlantic 39 242 

South Atlantic .4 10 

South Central . 2 2 

North Central 21 96 

Western 10 21 

United States— Total ....;.. 76 371 

This seems like a rather disappointing report, but previous 
to 1907 but eight cities in this country had school nurses, 
and about two-thirds of those now possessing them have 
awakened to such needs and established them in the past 
year. You will note that seventy-eight per cent, of these 
cities and over ninety-one per cent, of the nurses are dis- 
tributed in northern cities. This is not so strange when you 
consider that comparatively few of the Southern cities 
have medical inspection. 

The true and ultimate objects of medical inspection 
of schools are safeguarding the health of the pupils and 
improving their physical and mental condition by removing 
those defects that interfere with the child obtaining a normal 
education with comfort. Medical inspection without 
nurses is largely one of records and statistics, while with 
nurses it means action taken and results obtained. No 
amount of talk can give more convincing proof of the abso- 
lute need of school nurses than the following comparative 
study of the results obtained by medical inspectors with 
and without nurses: 



SCHOOL NURSE 



59 



City of Philadelphia. 



RESULTS OBTAINED BY A MEDICAL INSPECTOR WHEN NOT 



AIDED BY A NURSE. 



Individual 

children 

reported 

upon. 

No. 

751 



Cases needing treatment 
reported upon as terminated. 
Kind. 



Defective vision. 
Hypertrophied tonsils 
Adenoids. 
Defective teeth . 



Results reported. 
Action. No action. 



No. 


No. 


Per cent. 


No. 


Per cent 


272 


70 


25.8 


202 


74.8 


338 


62 


18.4 


276 


81.6 


36 


5 


13.9 


31 


86.1 


152 


31 


20.4 


121 


79.6 



Totals 



798 



168 



21.1 



630 



78.9 



RESULTS OBTAINED DURING THE SAME PERIOD BY THE 

SAME MEDICAL INSPECTOR WHEN AIDED BY 

A SCHOOL NURSE. 



Individual 

children 

reported Cases needing treatment 

upon. reported upon as terminated. 

No. Kind. No. 


Results 
Action. 
No. Per cent. 


reported 
No 
No. 


action. 
Per cent 


704 
















Defective vision. 


441 


355 


80.5 


86 


19.5 




Hypertrophied tonsils . 
Adenoids 


104 
62 


68 
45 


65.4 
72.6 


36 

17 


34.6 
27.4 




Defective teeth . 


150 


138 


92.0 


12 


8.0 



Totals 



757 



80.0 



151 



20.0 



RESULTS OBTAINED BY MEDICAL INSPECTOR AIDED BY 

A NURSE. 



School 


Nurse. 


1. 
2. 
3. 

4. 


Nurse . 
Nurse . 
Nurse . 
Nurse . 


Total Nurse . 



No. 
of recom- 
mendations. 


Recom- 
mendations 
acted upon. 


Recom- 
mendations 
not acted upon. 


Per cent 
acted 
upon. 


. 324 


262 


62 


80.86 


. 445 


434 


11 


97.53 


. 320 


282 


38 


88.12 


. 265 


226 


39 


85.28 



1,354 



1,204 



150 



88.90 



60 



ADMINISTRA TION 



RESULTS OBTAINED BY MEDICAL INSPECTOR NOT AIDED 
BY A NURSE. 



School. Nurse. 

5. None 

6. None 

7. None 

8. None 

Total None 



No. 
of recom- 
mendations. 


Recom- 
mendations 
acted upon. 


Recom- 
mendations 
not acted upon. 


Per cent, 
acted 
upon. 


. 283 


83 


200 


29.32 


. 582 


152 


430 


26.12 


. 441 


94 


347 


21.31 


. 474 


91 


383 


19.2 



1,780 



420 



1,360 



23.6 



The following is a report of the work of the school nurses 
of Philadelphia for the year ending December 31, 1910: 



City of Philadelphia. 



Number of schools 

Number of nurses 

Number of old cases 

Number of new cases 

Number of cases cured 

Number of visits to schools 

Number of visits to home (old) 3,096 

Number of visits to home (new) 1,928 

Total number of visits to homes 

Number of visits to dispensary (old) 3,139 

Number of visits to dispensary (new) 2,007 

Total number of visits to dispensary 

Number of school consultations (parents) 754 

Number of school consultations (pupils) 2,687 

Total number of school consultations 

Number of school consultations (pupUs) 

Number of examinations for uncleanliness 

Number of examinations for Bureau of Municipal Research 



39 

9 

42,869 

16,341 

10,969 

5,108 



5,024 



5,146 



3,441 

2,687 

30,099 

737 



SCHOOL NURSE 



61 



DISEASES FOR WHICH PUPILS WERE TREATED, SCHOOL, 
HOME, AND DISPENSARY. 



Diseases. 
Defective vision 

Corneal ulcer . 

Conjunctivitis . 

Glass 65^6 . 

Cataract 

Other diseases of the eye 

Defective hearing. 

Otorrhea . 

Other diseases of the ear 

Hypertrophied tonsils 

Adenoids . 

Defective speech 

Other diseases of the nose 

and throat . 
Pediculosis 
Eczema 

Pustular dermatitis 
Impetigo . 
Ringworm . 
Scabies .... 
Wounds 
Other diseases of the skin 
Scoliosis 

Hip-joint disease . 
Other orthopedic 

eases 



Teeth . . 

Malnutrition 

Nervous 



No. of 
cases. 



No. of 
patients 
cured. 



1,656 1,217 



4 
379 



296 
43 
64 
71 
768 
119 
29 

387 

6,376 

599 

124 

193 

206 

69 

1,841 

1,315 

5 



dis- 



Mentally deficient 
Tuberculosis (two sus- 
pected tuberculosis) 

Trachoma 

Miscellaneous .... 



33 



828 
142 
" 30 



4 

52 

706 



7 

350 

1 

1 

306 

26 

67 

55 

443 

80 

13 

491 

3,108 

578 

109 

159 

192 

55 

1,462 

991 

7 

1 



479 

129 

22 



glasses — 1,028 pairs; number 
of examinations for glasses 
not required, 189. 



(removed) . 
(5 operations). 



(211 operations), 
(28 operations). 



29 1 brace and shoes obtained; 
13 sent to gymnasium; 1 
operation. 



89 sent to country. 

1 sent to epileptic hospital; 2 
sent to country; 1 sent to 
Spring City; 2 old cases ad- 
mitted to Oakbourne Home. 



1 (sent to country). 
49 
541 



Total . 



16,.341 10,969 



62 ADMINISTRATION 

The school nurse has opened a path to the development 
of an ideal system of betterment of public health in our 
cities. The school nurse of the future will be the municipal 
nurse, whose duties will include not only protecting the 
health of the school children, but also caring for infants, 
teaching mothers their hygiene and proper feeding, thereby 
reducing a great and unnecessary mortality. By improving 
housing and living conditions, she will reduce the mortality 
from tuberculosis, pneumonia, and other preventable dis- 
eases. She will be the supervisor of health and sanitation in 
the factories as well as a teacher of hygiene to the children 
at school and to their parents at home. She will be the 
connecting link between the destitute family and the numer- 
ous organizations dispensing aid. With a small district 
assigned to a nurse in which she is held responsible for the 
health of every person and sanitation of every house, 
results can be obtained which would be impossible by any 
other system. The school nurses of the future are destined 
to be the guardians of our public health. 



SYSTEMS OF INSPECTION. 

Various bad features are noted in the systems employed 
in the different cities. Some cities are hampered by a law 
which permits the doctor and nurse supervising only con- 
tagious diseases. This prevents them from recommending 
or treating some of the most important ailments of school 
children, such as defective vision or hearings, enlarged 
tonsils and adenoids. Some cities have too few doctors 
and nurses to attend to the work, or the allotment of terri- 
tory is poorly arranged. Consideration must be given to 
the distances between schools, and the kind of and not 



SYSTEMS OF INSPECTION 63 

number of population in a district. A nurse or doctor can 
attend to more schools in a section of a city inhabited by 
the higher social classes than the doctor who attends the 
schools among the congested and foreign element. In some 
schools the physician may see no more than a half dozen 
patients a month, whereas in the district of poorer people 
each school may send daily from twenty to fifty patients. 
School population is not a safe guide by which to allot the 
work. Sometimes a smdl annex with one hundred children 
takes as much time to inspect as a school of one thousand 
pupils. 

Through a lack of understanding of the duties of the 
doctor and nurse, in some schools there is a waste of valuable 
time disposing of trifling wounds, etc., when the same time 
could be used for more important examinations. There is 
no need of a teacher sending to the inspector the same 
child with the same ailment each day, and the nurse 
should judge when she desires the doctor to again see the 
patient. 

Instead of examining and reexamining normal children, 
every new child should receive a thorough physical examina- 
tion on being enrolled. 

There are almost as many different systenls employed 
as there are cities in which the work is performed. 
In considering the adoption of a system one must be 
mindful of the duties of the inspectors, which should 
embrace : 

1, The detection of contagious diseases, thereby protect- 
ing the child and the community. 

2. The detection of physical defects, which may prevent 
the child from acquiring an education, and the correction 
of these defects which may add to his physical and mental 
development. 



64 ADMINISTRATION 

3. To find the capacity of the individual child to acquire 
knowledge in accordance with his mental and physical 
status. 

4. To insure the best possible hygienic surroundings for 
the child while he is in the charge of the school. 

5. To bring a closer relationship between the school and 
the home; to carry out more successfully the other aims 
of medical inspection and insure treatment for defects. 

6. To teach hygiene and healthful living that may be 
practised at school and home. 

To accomplish all of the above objects of medical inspec- 
tion, trained physicians should be employed. The examina- 
tions made exclusively by nurses or untrained and uninter- 
ested inspectors are often incomplete, inaccurate, and of 
slight value, and little information is secured that is of use 
to the teacher in the education of the child. 

Where the physicians are required to attend both morning 
and afternoon sessions, the morning may be employed in 
examining cases of suspected disease and defects found by 
teachers and nurses, and the afternoon utilized for complete 
physical examinations of the pupils. This should progress 
with sufficient rapidity, so that every child shall receive 
such an examination at least once a year. 

Class-room examinations of all the pupils are necessary 
after finding a case of contagion. These examinations are 
also of value in making a preliminary survey of the defects 
existing in a school. 

Class-room inspections are conducted as follows: The 
physician stands with his back toward a window and the 
pupils pass in front of him in single file. At his side are the 
nurse and teacher of the class. Each child as it approaches 
the physician with outstretched hands and head elevated 
to give a full view of face, turns hands to show both sides. 



SYSTEMS OF INSPECTION 



65 



The physician quickly observes the face for eruptions, 
sore eyes, discharge from ears or nose, enlarged glands, etc. 
The child is instructed to open mouth wide and say, 
"Ah! Ah!" This gives a fair view of the throat for condi- 
tion of tonsils and uvula and also condition of teeth. Hands 
are inspected for peeling or eruptions. While the doctor 

Fig. 3 



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I ^H 


^JL ^ ■^'wBWHBP^^^ 


bhB 


1 




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fm 



Class-room inspection. 



is busy with these observations, the nurse glances at hair 
and scalp for vermin and observes the condition as to 
general cleanliness. 

The teacher, supplied with paper and pencil, notes the 
name of any child to whom the doctor calls attention and 
places after the name a number given by the physician. 
These numbers represent a code easily remembered by the 
physician. 
5 



66 ADMINISTRATION 

1. Head and scalp. 

2. Eyes. 

3. Nose. 

4. Throat. 

5. Ears. 

6. Skin. 

7. Uncleanliness, 

X. Special, meaning an important case requiring imme- 
diate attention, such as a suspicious contagious disease. 
The physician collects these lists as he leayes the class-room, 
and upon returning to the room set apart for his examinations 
sends for these cases, several at a time, and makes a more 
thorough examination to confirm the diagnosis, and gives 
instructions. 

This system is employed in a number of cities, and its 
effectiveness depends upon the skill of the physician in 
quick and accurate observations. No two men would obtain 
the same results with the same pupils, and the method is 
useless for final diagnosis. Children with suspected ail- 
ments must be noted or taken out of line and given a more 
thorough inspection. 

In communities where they depend upon teachers to send 
the inspector to cases they believe require the attention of 
the physician, there is the disadvantage of relying upon indi- 
viduals with inexperience and limited knowledge in detecting 
cases. One teacher may send great numbers of cases that 
are unimportant and cause needless waste of the physician's 
time; while others may send none, often overlooking chil- 
dren suffering from contagious diseases or gross physical 
defects. 

Physical examinations, or what are termed in some 
cities, "individual examinations," are conducted for the 
purpose of detecting any variations from the normal that 



SYSTEMS OF INSPECTION 67 

may interfere with the health, growth, and development 
of the child. Some cities have laws or rules which forbid 
the physician touching the child during an examination. 
This is absurd in many respects, as medical authorities 
know the impossibility of detecting conditions of nose and 
throat, eye diseases, such as trachoma, chest diseases, such 
as tuberculosis, or defects of heart, without touching the 
child. Some authorities contend that the duties of the phy- 
sician are only preliminary to a more accurate diagnosis 
by family physician or dispensary. This may be true, 
nevertheless it results in the recommendation of many 
cases for examination which later prove normal. Further- 
more, these mistakes, due to snapshot diagnosis, often cause 
ill-feeling with parents, and also give to parent, teacher, and 
attending physician the erroneous impression that the medi- 
cal inspector knows very little about medicine. It lessens 
the confidence in the school physician and is detrimental 
to the reputation of municipal work. 

Cities vary in the frequency of visits required of their 
inspectors; some stipulate daily visits, while others twice a 
week or weekly. This question should be governed by the 
class of school population. The need of daily inspection 
or visits depends upon the number of cases referred to a 
physician in each school. In the same city those schools 
that care for children of the foreign population and tene- 
ment district should be visited daily, while those in better 
sections may require but two or three visits per week. 

In estimating the work performed by medical inspectors, 
the amount of time spent, the number of schools visited, or 
the number of pupils seen is no criterion. Great distance 
between schools may mean that the major part of time is 
spent in travel. One inspector may accomplish more in 
one hour, due to better training and ability, than another 



68 ADMINISTRATION 

in three hours. Great numbers of pupils examined and few 
defects discovered and remedied mean Httle progress to the 
work. 

In Philadelphia at the opening of schools in September, 
and again in January, the inspectors make a complete and 
exhaustive report of the sanitary conditions of school 
buildings, and defects noted are referred to the Board of 
Education. Then all new pupils recently admitted are 
examined for evidence of successful vaccination. 

By the act of legislature in Pennsylvania, "The medical 
inspectors shall at least once each year, inspect and care- 
fully test and examine all pupils in the public schools of 
their districts, giving special attention to defective sight, 
hearing, or other disabilities and defects specified by the 
Commissioner of Health in his directions for the medical 
examinations of schools." 

"The medical inspector shall at least once a year, and as 
early in the school term as possible, make a careful examina- 
tion of all privies, water-closets, urinals, cellars, the water- 
supply and drinking vessels, and utensils, and shall make 
such additional examinations of the sanitary condition of 
the school buildings and grounds as he deems necessary, or 
as the regulations of the State Department of Health or 
the rules of the board of school directors or of the local 
board of health requires." 

RECORDS AND SYSTEMS OF RECORD KEEPING. 

Much of the success of school medical inspection, its 
administrative control, results obtained and tabulation of 
statistics of value depend upon the records and system 
of record keeping. It is to school inspection what book- 
keeping is to a merchant. 



RECORDS AND SYSTEMS OF RECORD KEEPING 69 

Records are needed for the carrying on of the present 
work, the index of our activities and results, and the guide 
for future work. Medical inspection involves responsibility 
of several classes of workers, the doctor, the nurse, the 
teacher, the principal, and the parent. Each has special 
and individual responsibilities which coalesce, and each 
must assume his part to assure success. The records and 
system employed are the medium of cooperation between 
all parties. 

The records are needed in compiling and tabulating 
weekly, monthly, and annual reports, and also in compiling 
statistics of value to ourselves and others to extend and 
improve the activities. 

While there are occasional attempts of uniformity in 
performing the work, few cities use the same system of 
records. The greatest progress will be attained when most 
of the cities and towns having school inspection will adopt 
a uniform system. Work and results may then be compared 
to the benefit of all cities. Some copy the forms used by 
others, adding new ones, and a few discarding part of the 
system copied. Forms are often adopted without a knowl- 
edge of their practicability. Many cities change their 
forms frequently, showing the present undeveloped condi- 
tion of many systems. To enumerate and reproduce speci- 
mens of the forms used by various cities would require a 
volume and tend only to confuse the reader as to which 
are good and which are faulty. For our purpose it will 
suffice to enumerate some of the bad features of some of the 
systems. 

Some cities have entirely too many forms, often dupli- 
cating clerical work and complicating the system, and sim- 
plicity is seldom the keynote. To some cities the expense of 
printing forms is no small item. Many of the blanks are 



70 ADMINISTRATION 

long on columns and short on information of actual value. 
The number of medical, sociological, and pedagogical ques- 
tions which may be asked are unlimited, but the records 
should contain such information which is of practical value 
in decidiDg what action to take in the average case. It 
is undesirable and unnecessary to have a separate form to 
meet each emergency. The doctor and nurse frequently 
recording the time consumed in the performance of each 
duty is of little value, and such blanks are designed more 
for keeping tabs on the doctor and' nurse than on the pupils. 
Complete and accurate records are necessary, but it is 
useless transcribing the same information a number of times. 
When fifty or seventy-five per cent, of the physician's time 
is needed for clerical work, it would be economy to furnish 
him with a clerk. 

One city uses five distinct and separate forms for each 
case, one for the teacher, which remains in the school as 
a permanent record, one for the nurse, one for the health 
department, one for the parent, and one for the medical 
inspector. Aside from the unnecessary expense and waste 
of time, such records cannot be referred to intelligently. 
Duplicate copies made by the use of carbon paper while 
saving time admits of copies which blur and cannot be kept 
for permanent records. All forms which are referred to 
frequently should be printed on card-board and not on paper. 
All information which is of value to the work should be 
recorded, on one blank, arranged and filed in a manner to 
be available at a moment's notice. 

Systems of record keeping in some cities are so faulty 
that they are useless when compiling statistics. Annual 
reports may show the number of examinations of children, 
but not the number of children examined ; hence, percentages 
of defects found cannot be estimated. 



RECORDS AND SYSTEMS OF RECORD KEEPING 71 

A preliminary survey of a school of two thousand taken 
while the pupils pass in front of the inspector, the entire 
work taking one hour, should not be recorded as two thou- 
sand examinations, and as often happens, included with, say 
ten individual thorough examinations, taking three hours, 
but should be recorded as so many classes examined. 

Diseases and defects among the pupils are obtained from 
three sources: (1) Detected and sent by the teacher, (2) 
class-room inspections, and (3) individual examinations. 
There is no need for a separate blank to record the cases 
from each of these sources. The teacher in surveying her 
class each morning before beginning her exercises, should 
recognize the pupils requiring the attention of the attending 
physician, and note the name of child, class number, and 
reasons for referring to the doctor. The physicians record 
the diagnosis and recommendation on the same blank and 
passes the card on to the nurse. Defects found by class 
inspections or individual examinations may be recorded 
on similar forms. 

Defects which may influence the education of the child 
should be transferred to the card used to record the child's 
school attendance and progress. This report card should 
follow the child through the various grades and schools. 

After studying the various systems of medical inspection, 
as employed in a number of cities of the United States, 
and eliminating the useless and unpractical features, the 
author devised a system of inspection which has met all of 
the requirements for a simple and practical system. Gulich 
and Ayres, in their Medical Inspection of Schools, commends 
this system, and much of it has been adopted in Philadel- 
phia and several other cities. While the blanks were devised 
for schools employing doctors and nurses, it is equally 
applicable to those having only physicians. 



72 ADMINISTRATION 

In devising the system, the chief factors considered 
were: (1) The eHmination of useless clerical work; (2) 
methods which would assure cooperation between the medical 
inspector, nurse, principal, teacher, and parent; (3) the 
avoiding of unnecessary exclusion of pupils, and when ex- 
cluded, their return in the shortest possible time; (4) the 
assuming by each party of his or her share of the responsi- 
bilities, so errors or derelictions may be traced to their 
source; (5) records and reports to be as few as possible, 
to afford simplicity, practicability, and easy reference at 
all times. 

The system comprises the use of but one card, which 
is used to refer all cases and serve as a record for recom- 
mendations and actions taken. Some of these cards are in 
each class-room, and the teacher answers the questions and 
information desired on the upper part of the card, and sends 
it with the pupil to the inspector. This may seem to add 
more clerical work on the already overworked teacher, but 
it has been proved to save her time, trouble, and respon- 
sibility. Many of the younger pupils do not know their 
names, addresses, and number of classroom, much less why 
the teacher sent them to the doctor. The return of the pupil 
to its teacher requesting the desired informations means 
loss of time and the answer eventually sent upon any scrap 
of paper requiring copying by the doctor and nurse. The 
teacher filling the cards out before beginning her session's 
work, avoids the unwise plan of asking, "Who wishes to 
go to the doctor?" with a ready response from shiftless 
pupils who desire an excuse for leaving the class. The teacher 
personally observes who should be sent to the physician, 
and states on the card the reason for sending the child and 
avoids many cases of imposition. 



RECORDS AND SYSTEMS OF RECORD KEEPING 73 



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74 ADMINISTRATION 

The above report cards can be printed on two different 
colors of card-board. Blue cards for cases recommended 
for treatment ; yellow cards for cases excluded for contagious 
diseases. By this distinction in colors, one can readily 
refer to the excluded pupils and follow them up to have 
the children returned at the earliest possible date. 

In schools having a system of bells, the physician on 
visiting the school rings the bells on each floor a number 
of taps, which informs the teachers of his presence. Imme- 
diately the children are sent to him with their respective 
cards. In schools having no bells, each morning the teachers 
send to the principal's office the cards of the children to be 
examined, and the inspector sends to the classes for these 
pupils. The diagnosis and disposition of the case are written 
on these same cards, which are kept in the office. Each 
pupil sent to the inspector for examination receives one of 
the following slips to take back to his teacher : 

To Teacher— 

This child is referred for treatment to 



Nurse. 
Dispensary. 
Family Physician. 

This child is excluded from the class-room 

until you receive notice for his (her) return. 

Medical Inspector. 

When a child is excluded, it may be given a card similar 
to the following, to take home to its parents : 



RECORDS AND SYSTEMS OF RECORD KEEPING 75 



Division of School Inspection. 

Department of Public Health and Charities. 

bureau of health. 

Room 612, City Hall. 

Philadelphia, 19. 

Name , Age 

Address 

Is Ordered to Discontinue Attendance at 

_ School located of _ 

Reason _ _ _.._ _ 



Medical Inspector. 

(See Other Side). 

Notice to Parents. 

The disease mentioned on the other side of this card is a 
contagious affection and liable to be transmitted to other, 
children. The child should receive prompt treatment by a 
physician (or at any dispensary), and should return to school 
, 19 , for reexamina- 
tion by the Medical Inspector of the Bureau of Health. 
If found free from contagion at this time, he may resume 
attendance at school. 

Chief Medical Inspector. 

On the tab returned to the teacher the doctor underscores 
whether the pupil is to go to the nurse, dispensary, or family 
physician for treatment, or whether excluded from the class. 
This admits of no mistake by the teacher, and aids her in 
knowing the exact nature and disposition of each case. 
The child cannot go home for the remainder of the day when 
he was instructed to wait for treatment by the nurse; and 
again, a child excluded cannot return to his seat in the class- 
room and the teacher remain ignorant of his exclusion by the 



76 ADMINISTRATION 

inspector. It admits of the principal having a full written 
record of the disposal of all cases sent to the doctor. 

When the case is referred to the nurse, the doctor specifies 
on the card if the child is to be treated at home or at school, 
or both; also the treatment recommended. This concise 
written report makes mistakes impossible, and may prove 
valuable if legal or other questions arise. These cards are 
filed in the office in a box with three compartments : (l) New 
cases; (2) unfurnished cases; (3) cured cases. Each com- 
partment is arranged according to the number of class-rooms. 

The nurse on visiting the school, first takes all cards in 
the compartment of new cases and sends for each pupil 
individually. The information on the card makes it pos- 
sible for her to perform all her work without troubling the 
principal or teachers. After attending to the new case 
and recording on the card the date of treatment, she replaces 
them in the cabinet in the compartments of unfinished or 
cured cases. The nurse now looks over the unfinished 
cases and sends for those requiring treatment and records 
the date. She so proceeds each day until the child is cured 
or the case otherwise terminated, when she records the 
date of cure, when the card is filed in the third compartment. 
Once a month all finished cards are sent to the Bureau of 
Health of Education, where they are filed in a cabinet 
according to school and disease. One can readily perceive 
how easy it is to refer to these records. For example, 
should one desire to know how many cases of defective 
vision were treated and obtained the necessary glasses, or the 
average number of treatments required at school to cure a 
certain skin disease, these facts may readily be obtained. 

The physician and the nurse render to their superior 
officers a daily and weekly report of the work performed. 
These reports are tabulated from the individual record 
cards kept at the schools. The report should be filled in 



RECORDS AND SYSTEMS OF RECORD KEEPING 77 

each day and mailed to the chief inspector at the end of 
the week. 

A form suitable for recording the work performed by the 
nurse each day and totaled for the week is herewith shown: 

Report for Week Ending, 191 

Nurse. 



M. 



W. 



Totals ! Home ' Disp'y 



Cured 



Date 



Schools Visited 
Old Cases 
New Cases 
Cured 

Visits to f Old 
Homes \ New 
Taken to j Old 
Disp'y \ New 
School [Parents 
Consul--) 
tations [ Pupils 
Exams, for 
Uncleanliness 
Def. Vision 
Corneal Ulcer 
Conjunctivitis 
Other Diseases 
Def. Hearing 
Otorrhea 
Other Diseases 
Hypert. Tonsils 
Adenoids 
Def. Speech 
Other Diseases 
Pediculosis 
Eczema 
Pust. Derm. 
Impetigo 
Ringworm 
Scabies 
Wounds 
Other Diseases 
Scoliosis 
Hip-joint Dis. 
Other Diseases 
Teeth 

Malnutrition 
Nervous 

Totals 



78 ADMINISTRATION 

School clinics, especially for some of the specialties, 
diseases of the eye, or nose and throat, have been inaugu- 
rated in several cities. These clinics are intended only for 
the treatment of school children whose parents cannot 
afford to obtain such services from a private physician. 

To avoid dispensary abuse by free school clinics, each 
child should be investigated by the nurse or social visitor 
at its home to be assured that the parents cannot afford to 
pay. When a child is found to be a suitable case for free 
treatment, the nurse or medical inspector should fill in 
one of the accompanying blanks. One of these blanks 
properly filled in and signed by the nurse and principal is 
presented at the clinic when the child applies for treatment. 

City of Philadelphia. 
Department of Public Health and Charities. 

BUREAU OF health. 

division of school inspection. 

Dental Dispensary, 

Room 706, City Hall. 

Philadelphia, 191 

This is to Certify that age 

Residence School... Section Grade... 

is in need of dental treatment and the parents are unable to pay 
for the same. 



Inspector. 



Principal. 



Present this Certificate at Room 706, City Hall. 

Office Hours: Monday to Friday, 9 a.m.- to 4 p.m. 
Saturdays, 9 a.m. to 12 noon. 



RECORDS AND SYSTEMS OF RECORD KEEPING 79 

Department of Public Health and Charities, 
bureau of health, room 708, city hall. 

L. C. Wessels, M.D., Philadelphia,.. _ 

Ophthalmologist. 

This is to Certify that age _. 

Residence School Section Grade 

is in need of glasses and the parents are unable to pay for the 
same. 



Medical Inspector. 
Principal. 



The medical inspector should when leaving a school, 
take an account of the work he performed that day. He 
should note a summary of the number of examinations,, 
cultures, vaccinations, etc., also exclusions and diseases 
for which pupils were excluded, and recommendations for 
treatment. These items should be totaled at the end of 
the day and written on the "Weekly Report" sheet, 
which is to be returned to the central office. These notes 
may be kept on one of the weekly sheets, using a blank 
for each day and placing name or number of school in place 
of the day or week. 

"Weekly Report" sheets should show a complete detailed 
history of the work performed. These reports are the only 
record which the supervisor has to scan each week to know 
the character and quality of work performed by the various 
inspectors. It is important that the supervisor should 
keep at his office a "blotter" or large sheet containing all of 
the columns recorded on a weekly report blank, and a space 
for each inspector. 



80 



ADMINISTRA TION 



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RECORDS AND SYSTEMS OF RECORD KEEPING 81 







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82 ADMINISTRATION 

The reports are transferred to this "blotter," where 
they can be added to find the total work performed 
by the entire corps during the week. It also serves 
to make comparisons of the work performed by each 
inspector. The chief or supervisor has formed averages for 
each disease excluded or recommended for treatment. He 
can study from these sheets the shortcomings of the men 
under his charge. He receives his suspicions as to where 
he should personally visit, observe and instruct to make 
the work uniform and effective. 

When the individual record cards, which have been closed 
because the defects or diseases have been treated and cured, 
have been returned to the central office, they should be 
counted to see if they tally with the numbers reported by 
the inspectors. 

The preceding form is recommended for a "weekly 
report" of the work performed by a medical examiner. 



AUXILIARIES TO SCHOOL INSPECTION. 

The medical and sanitary inspection of schools is not a 
problem for the physician alone, but requires the concerted 
action of all parties concerned. School authorities, princi- 
pals, teachers, nurses, parents, and institutions allied to the 
medical profession, such as hospitals and dispensaries, must 
work harmoniously and add their quota to the work to 
accomplish results. 

Teachers and Principal. — The interest manifested by the 
teachers and principal contribute greatly to the success of 
school inspection. Indifference on the part of a teacher 
may allow an epidemic of a contagion to spread by failure 
to recognize a sick child and in sending it to the inspector 



AUXILIARIES TO SCHOOL INSPECTION 83 

for diagnosis. Thus poor results in teaching are obtained 
because pupils suffering from uncorrected physical defects 
are permitted to remain in class. 

Cooperation between the school and the doctor depends 
largely upon the physician's diplomacy. He can do much to 
stimulate interest in his work by occasional talks at meetings 
of the. teachers. On these occasions the physicians can 
train the teachers to recognize certain diseases and defects. 
Instructive talks by the principal will also awaken interest. 
Fortunately, few teachers and parents are now ignorant of 
the benefits derived from medical inspection, and many 
welcome the work. The antagonism exhibited by some 
teachers during the early days of medical inspection was 
mainly due to a mistaken idea that it would place additional 
work upon them, but when they found that the recognition 
of defects and their treatment eliminated many of the back- 
ward and unruly pupils and lightened their burdens, their 
indifference ceased. 

Teaching of Hygiene. — ^The value of school inspections is 
measured by the results obtained and the permanency of 
the effects, not by the number of children examined and per- 
centage of defects found. To correctly diagnosticate a defect 
or disease is the first step of medical school inspection; 
to recommend treatment is the next; and third, and most 
important, to have the defects corrected. Here the physi- 
cian is dealing with parents of all temperaments, and only 
by the exercise of good judgment, tact, and diplomacy will 
he succeed in arousing some parental action. 

Public hygiene and sanitation, of which school inspection 
is a part, aims not to cure disease but to prevent it. The 
best method of preventing sickness among school children is 
to teach healthful living. A part of all public health work 
must be educational, and the condition of good health will 



84 



ADMINISTRA TION 



be most marked where the people learn and practise the 
requirements of hygiene. The child must learn what causes 
certain diseases and how to protect himself and others. 
This knowledge is not only a lasting benefit to the pupil, 
but to those with whom he comes in contact at home and 
elsewhere. 

Fig. 4 




Teaching school girls practical hygiene and care of infants. 



Every opportunity should be taken to teach practical 
hygiene in the class-room. Incorrect posture in standing or 
sitting should be occasion to explain to the class its dangers. 
Practical lessons at opportune times make lasting impres- 
sions and a certain number of hours each week should be 
devoted to the subject. Text-books should be selected 



AUXILIARIES TO SCHOOL INSPECTION 85 

which are practical and written in an interesting style, that 
will appeal to a child. In the first grades, stories with 
hygiene lessons as their basis are instructive. Anatomy 
and physiology should always be illuminated with practical 
lessons on hygiene. 

If tiie teeth are under consideration, the child should be 
taught the value of good teeth, the pain and discomfort 
with decayed teeth, the change in shape of the face through 
their loss, and how to preserve them. In a similar way the 
various parts of the body can be taken up. Instead of merely 
describing a bone of the spinal column, explain at the same 
time curvature of the spine and its causes. 

The medical inspector when present at the time of a lesson 
in antomy, physiology, or hygiene may aid in the instruc- 
tion. 

School Text-books on Hygiene. — To insure good teaching, 
there must be good text-books. No other subject in the' 
school curriculum has received such little attention by com- 
petent authors as practical hygiene. Hampered by rules 
of school boards, which govern the subjects written upon, 
the scope of the work, and the authors, who are seldom 
medical men trained in public health problems, little can 
be expected of the class of books published. The children 
should be systematically instructed in the principles of 
sanitation and hygiene according to their age and recep- 
tiveness. The text-books must be M^ritten in a simple 
manner, and suitable for school use. Personal hygiene is of 
more importance than general and public hygiene, and a 
study of rare diseases can be profitably omitted. Likewise, 
inadvisable are gross exaggerations of the evil effects of 
alcohol and tobacco, which ascribe every ill to which the 
body is heir to the use of these drugs. Hygiene should be 
designed as a progressive study, adapted to the varying 



86 ADMINISTRATION 

capacities of each class from the primary to those more 
advanced. The facts should be developed and advanced 
from grade to grade^ always keeping within the limits of 
comprehension. The same truths repeated and gradually 
enlarged become part of the child's stock of intelligence; 
he learns, yet scarcely remembers when or how, and the 
lessons stick and influence his future life. To instruct, one 
must interest, and this is accomplished by well-written 
incidents from everyday life. Illustrations should be care- 
fully selected to appeal to a child, and with a view toward 
helping to understand the text. 

Parents. — There always will be a few parents who through 
indifference, ignorance, or neglect are unmindful of the phy- 
sical needs of their children. Nothing has encouraged co- 
operation between home and school more than medical 
inspection of school children. The physician and the nurse 
with their home visits and school consultations have obtained 
remarkable results. The parents are shown that their 
children are not only receiving instruction in arithmetic 
and languages, but that the school authorities are interested 
in everything that concerns the physical, mental, and moral 
development of their charges. This interest on the part of 
the school, however, should not relieve parents of their 
responsibilities. Wherever possible they should do their 
share and be encouraged to render the assistance that is 
their duty. 

Parents' meetings at the school, held in the evening when 
parents are free from home duties, are invaluable. Here 
the school physician can with interesting lectures accom- 
plish much that will benefit the home and the children, 
and incidentally aid him in his work. If these lectures 
are illustrated by means of lantern slides, the public may 
be more readily instructed in the work performed by school 



< 




Q. 



o 



AUXILIARIES TO SCHOOL INSPECTION 87 

physicians, the protection against prevalent diseases and 
other public health problems. 

Specialists. — Accuracy in diagnosis is needed to prevent 
spread of contagion. The physician, if in doubt regarding 
a suspicious case, cannot with impunity allow a child to 
remain at school while he watches the developments, nor 
can he wait twenty-four hours for the result of a culture to 
verify the diagnosis of a suspicious diphtheria. For these 
reasons some system should be adopted similar to that in 
Philadelphia which employs two experts as diagnosticians, 
to whom are referred all cases in which the medical inspector 
is in doubt as to the diagnosis. In the above city these 
services have proved of great value. 

Special School Clinics. — In America little has been done 
to create school clinics, but abroad they are a feature of 
school medical inspection. In this country, eye and dental 
inspections are the only clinics held directly in connection 
with school work. Sixty-nine cities in the United States 
have inspections conducted by dentists, most of whom 
give their services gratis, but several cities including New 
York and Philadelphia have dental clinics as part of school 
inspection. Philadelphia has a corps of paid dentists who 
devote time every day to the school children at a clinic 
fitted out at the City Hall, and two clinics in downtown 
schools. This city also has a clinic in the same building in 
charge of a competent ophthalmologist for the examination 
and treatment of the eyes. 

Dispensaries and Hospitals. — It is evident that dispensaries 
and hospitals are necessary adjuncts to the physician's 
work in the schools. School medical officers in most cities 
are forbidden to treat any child attending the schools 
under his supervision. This is a wise ruling, as it prevents 
the possibility of abuse of power and interference in the 



ADMINISTRA TION 



work of attending physicians. All patients are referred to 
their parents or guardians, to be taken to their family 




physician, or if too poor, to a dispensary. The school 
doctor and nurse must be informed of the dispensary hours 



AUXILIARIES TO SCHOOL INSPECTION 89 

for the various specialties at the different hospitals. Where 
clinic hours interfere with school sessions, arrangem.ents 
can be made with some hospitals to have special clinics 
after school. 

Social Visitors. — Parental neglect, ignorance, poverty, and 
many social aspects must be studied constantly, because 
it is these conditions which make it difficult to arouse 
parents to take some action on recommendations of the 
school physician. The trained school nurse is the best 
solution of the problem. However, in some cities where 
nurses are not employed, social workers and visitors are of 
service. They can visit homes, interest parents in the neces- 
sity of giving proper treatment, and, where poverty exists, 
seek the aid of one of the charity organizations when neces- 
sary. In some cities the percentage of cases which receive 
treatment is but a small fraction of those recommended. 
■This is oftentimes due to neglect to study social and home 
conditions and apply efforts in those directions. 

While some States have compulsory examination of school 
children, no State or city has any law which compels a parent 
to act upon the recommendations of the physician. Irre- 
spective of the non-existence of such statutes in cases of 
stubborn parents, much can be accomplished by the tactful 
trained nurse, the proper use of the Society to Protect 
Children from Cruelty, and the bureau of compulsory 
education. However, the two latter institutions should 
not be resorted to until all other means have been ex- 
hausted. In Pennsylvania the compulsory education laws 
cannot legally be used for this purpose, as the code states, 
"Any pupil prevented from attending school on account 
of the health or sanitation laws of this Commonwealth is 
hereby relieved from complying with the provisions of this 
act concerning compulsory attendance." 



90 ADMINISTRATION 



INSPECTION OF TEACHERS AND JANITORS. 

The health of the teacher is of great importance to the 
public school system, in some respects even more so than 
the pupils under their care, and yet little has been done to 
assure by inspection a normal staff of healthy teachers. 

Tacoma, Washington, has a law that excludes from school, 
teachers and janitors as well as children afflicted with 
tuberculosis. Pennsylvania has a similar section in its 
School Code, "No person having tuberculosis of the lungs 
shall be a pupil, teacher, janitor or other employee in any 
public school, unless it be a special school carried on under 
the regulations made for such schools by the Commissioner 
of Health." 

A teacher or janitor with such diseases as tuberculosis, 
especially tuberculous affection of the throat, consumption, 
coupled with carelessness in spitting or uncleanliness, and 
syphilis in certain stages, may produce untold harm if 
unrecognized. There are other ailments which when pos- 
sessed by a teacher while not communicable are detrimental 
to the education of the pupils. Extreme nervousness and 
irritability, whether due to general physical breakdown or 
some existing defect, is sure to give results which react on 
the pupils. Chronic laryngeal catarrh, defective hearing 
or vision and many other defects in the teacher should be 
recognized as of more importance than in a pupil. 

The mere furnishing of a certificate of health to the board 
of education is insufficient, as there are some unthinking 
or unscrupulous physicians who for the sake of a fee may 
issue such a certificate to a teacher when they know she is 
suffering from some defect that may prove detrimental to 
the school. 



INSPECTION OF TEACHERS AND JANITORS 91 

In the State of Massachusetts the law says the medical 
inspector shall make " such further examinations of teachers, 
janitors, and school buildings as in his opinion the protection 
of the health of the pupils may require." 

The School Code of Pennsylvania reads: 

Section 1320. "No teacher's certificate shall be granted 
to any person who has not submitted upon a blank furnished 
by the Superintendent of Public Instruction a certificate 
from a physician legally qualified to practise medicine in 
this Commonwealth, setting forth that said applicant 
is neither mentally nor physically disqualified — by reason 
of tuberculosis or any other chronic or acute defect, from 
successful perforinance of the duties of a teacher; nor to 
any person who has not a good moral character, or who is 
in the habit of using opium or other narcotic drugs in any 
form, or any intoxicating drinks as a beverage." 

The foregoing is evidence that a few States are alive to 
the importance of medical inspection of teachers and other 
school employees, and have taken steps to safeguard the 
pupils. The importance of a normal staff of healthy teachers 
cannot be emphasized too strongly, and any community 
installing a system of school inspection must necessarily 
provide some form of legislation to cover this point if the 
system is to be complete and efficient. 



PART II. 

THE SCHOOL BUILDmOS AM GROUmS. 



INSPECTION OF SANITATION. 

An important part of medical inspection consists in the 
inspection of sanitation of school buildings and grounds. 
This is mandatory in some States, and the laws not only 
direct how such examinations shall be conducted, but also 
contain specific provisions for the erection of schools and 
planning of the school yards. One cannot teach hygiene 
and healthful living surrounded by unsanitary buildings in 
which to conduct classes. Attractive, well-ventilated, and 
well-kept school-rooms are in themselves an object lesson 
and an incentive for the pupils to try to live properly. 
For the medical inspector to recognize unsanitary condi- 
tions and faulty construction, he must be trained to know 
what is necessary to make a school building suited to the 
needs for which it was built. All defects must be properly 
noted and a report given to the authorities who have the 
power to remedy them. 

Inspections should be made at least once a year, and 
oftener if required. The inspection should include every 
part of the building, including its drainage, plumbing, 
heating, ventilation, cleanliness, etc. All urgent repairs or 
unsanitary conditions found should be noted in a special 



94 THE SCHOOL BUILDINGS AND GROUNDS 

report, and a reexamination made in a reasonable time to 
note what action has been taken. In some cities it may 
require a fearlessness on the part of the inspector to report 
certain shortcomings. 

Measurements and calculations should be made showing 
the amount of air space per pupil and the amount of window 
and lighting space. These should be placed on a record 
blank for permanent filing in the health department or the 
Board of Education. With it might be filed a plan of the 
building furnished by the architects. This information 
when once properly and fully recorded and filed, need not 
be taken again unless some changes or alterations are 
made to the building or ground. 

Reports must not be made on the word of teacher, prin- 
cipal, or janitor, but only by the personal observation of the 
inspector. While these authorities may call attention to 
defects which may otherwise be overlooked, all complaints 
should be verified by the physician. 

The medical examiner should begin his examination by a 
thorough inspection of the grounds surrounding the school. 
The out-houses, water-closets, and urinals should be in- 
spected for distance from building, ventilation, cleanliness, 
•condition of plumbing and drainage, number of seats in 
relation to school attendance, and accommodations for 
small children. The kind and condition of paving on school 
grounds, the presence of any stagnant pools of water, 
playground facilities, and the amount of space per pupil 
should be noted. 

The inspection of the building should include attics, 
basements, cellars, and all closets for cleanliness; also the 
kind of flooring in cellars, dampness of walls, presence of 
water, or accumulation of refuse and ashes. Study the kind 
and condition of the heating apparatus and the air intake, 



REPORTS ON SANITATION 95 

also whether such conduits are properly screened. The 
absence of a cellar, with building directly on ground, may 
greatly affect the health of the children. 

The inspection of class-rooms includes the measurement 
of each room to find the amount of air space allotted to 
each child and the amount of window space. The lighting 
should be studied in its relations to the pupils, and whether 
obstructed by adjoining walls. The seating of the pupils 
should be noted while the class is in session, as adjustable 
seats and desks may not be properly adjusted. The kind 
of desk and chair used should be noted in the report, also 
the temperature and humidity of each room and improve- 
ments where needed recommended. 

Coat-rooms and toilets should not be overlooked. There 
should be a separate hanger for each child and the coat- 
rooms should be ventilated. The indoor toilets should 
meet the requirements of the children, and flushing and 
plumbing should be in perfect condition. 

The water-supply is very important, and the source and 
purity should be investigated. If filters are used, they 
should be clean and in working order. The facilities for 
drinking and the use of individual cups or drinking fountains 
should be noted. 

All observations should be immediately placed on a per- 
manent record to be kept on file at the central office. It 
is surprising in how few cities the condition of school 
buildings is known. 



REPORTS ON SANITATION. 

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98 THE SCHOOL BUILDINGS AND GROUNDS 

These reports should be filed in the ofiice of the health 
department and all changes should be noted and filed with 
the first report. 



CONSTRUCTION OF SCHOOL BUILDINGS. 

General Considerations. — The construction of a school build- 
ing is beyond the scope of this work. It is considered here 
only in a general way for the purpose of helping the inspector 
to recognize those conditions that are unsanitary or detri- 
mental to the health of the children. Details of arrange- 
ment of rooms and the division of floor space should be 
according to available space and the needs of the occupants. 
The basement, often neglected, should receive considera- 
tion as to flooring, possible contamination from sewer gas 
or dampness, ventilation and light. Roofs should afford 
protection against rain or snow, and against the heat in 
summer. Ample provision must be made for playgrounds. 

It is essential that schools shall be built upon proper sites, 
and with due regard for adequate heating, lighting, and 
ventilation. There should be a sufficient supply of pure 
water, and the plumbing and drainage should be an 
approved sanitary system. 

Buildings should preferably be two stories high, and when 
higher should be fire-proof. Where space admits, a school 
should contain besides its class-rooms and administration 
offices, assembly halls, physical training-rooms or gym- 
nasiums, a room for manual training, sewing or cooking 
classes, and possibly a library. One of the rooms should 
be set aside for the work of the medical inspector and nurse. 
This room should be well-lighted and furnished with 
running water. 



CONSTRUCTION OF SCHOOL BUILDINGS 99 

The basement should be two-thirds above street level, so 
as to allow plenty of light and ventilation. The entrance 
can then be located in this part of the building when desired. 
Lockers placed in basement would prevent rain and snow 
being tracked through the building in bad weather. The base- 
ment could also be used on rainy days for recess or it would 
serve as a location for toilets and other lavatory equipment. 

The stairs should be wide enough to allow classes coming 
and going. The material for steps should be such as will 
not wear slippery or dusty. Railings should be constructed 
so as to be easily cleaned, the halls should be well-lighted 
and not dependent on light from class-rooms. Walls should 
be burlapped and glazed or of material that will stand wear 
and tear and cleaning. 

■ The Committee of Medical Inspection of Schools of the 
American Medical Association made the following com- 
ments after an investigation on the school buildings in 
this country, June, 1911: 

" Many schools are unfit for use and should be torn down. 
One-fourth of the schools need to be reconstructed. Recent 
school buildings are much better, and yet any number of 
faulty constructions are still going on. What is needed is 
a more vigorous educational campaign in what hygiene, 
sanitation, and efficient living require. What is still more 
needed is: 

"l. The endorsement of certain standards and require- 
ments in the planning and maintenance of school buildings 
and grounds by State and national educational and medical 
organizations. 

"2. The enactment of legislation which will define these 
standards and insure the erection and modification of school 
buildings in accordance therewith." 

The "Ten Commandments of School-house Construction" 



100 THE SCHOOL BUILDINGS AND GROUNDS 

by William E. Chancellor, of Norwalk, Connecticut, are 
well worth quoting: 

"1. Whenever possible, the school building should have 
sufficient ground and be so oriented on its plot that into 
every school-room the sunlight will come directly at least 
one hour each day. 

"2. Every school-house, whether in city or country, when 
over one story should be strictly fireproof. 

"3. Every school-house should haye at least two outer 
doors, for entrance and exit, with doors opening outward, 
and one outer door for every two rooms above four ground- 
floor rooms; and at least two stairways with an additional 
stairway for every two rooms above four upper-story rooms, 
stairways not over five feet nor less than four and one-half 
feet wide. In other words, the fire-proof building should be 
also as nearly panic-proof as human ingenuity and material 
resources permit. 

"4. In every school-house the halls should be well-lighted 
from end to end. 

"5. The toilet conveniences, when possible to avoid it, 
should not be placed in basements; either isolated towers 
or separate buildings should be used. 

"6. Every child is entitled to at least twenty square feet 
of floor space in each class-room attended, and to at least 
three hundred cubic feet of air space; to a complete change 
of air every eight minutes, and to playground space at least 
equal to class-room space. With artificial heating and 
ventilating systems the problem is extremely difficult. 
Fresh air taken into the heating chamber should be taken 
from a height of ten to twelve feet above ground. All air 
ducts should be kept free from dust. The heated air should 
contain the proper amount of moisture. The air ducts con- 
veying the foul air from class-rooms should be of sufiicient 
size and construction that the change of air is possible. 



CONSTRUCTION OF SCHOOL BUILDINGS 101 

"7. Unilateral or quadrant lighting has come to stay as 
the standard. With it has come the standard of not less 
than twenty nor more than twenty-five square feet of floor 
space as the lighting area. The arrangement of this lighting 
is a technical problem not well met thus far. 

"8. Each class-room should have its own separate 
wardrobe. 

"9. Each class-room should have two or three sets of 
lockers for books so that day and evening pupils or morning, 
afternoon, and evening pupils may use desks without 
interference with one another's property and without the 
resultant contamination and disease infection. 

"10. Hitherto the notion has been to fit the school pupils 
, into desks and chairs for book study. The new idea is to 
give to them space and opportunity for activity and develop- 
ment. It follows that the school, instead of being the mold 
for the pupils to fit, must itself be molded by the course of 
study. The old unit idea of fifty children to a room, and as 
many rooms of a standard size as there are classes of fifty 
children each, is giving way to the idea of the universal 
school with such rooms as these — viz.: (a) assembly and 
music halls; (b) physical training drill-rooms or gymnasiums; 
(c) drawing rooms; (d) offices and rooms for principal, 
head teachers, janitor, etc.; (e) science and art museums; 
(/) libraries and reading-rooms; (g) work-rooms for manual 
training, trades, handcrafts and domestic science and art. 
In every instance in which desks are used in class-rooms, 
the desk should be adjusted to the child and not the child 
to the desk." 

The total value of the public school houses in the United 
States is about nine hundred million dollars, and according 
to William E. Chancellor, one-half of them are so abominable 
that they should be razed to the ground. There are some 



102 



THE SCHOOL BUILDINGS AND GROUNDS 



ideal school houses, such as the Charlestown High School 
in Boston; the Wyman School, St. Louis; the Bernard 
Moos School, Chicago; Rosedale School, Cleveland, and the 
Morris High School, New York. 




z 
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b~ 
z 

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CONSTRUCTION OF SCHOOL BUILDINGS 



103 



The medical inspector may profit by studying the con- 
struction, and sanitation of some of these school buldings, 
which have ideal conditions. The accompanying diagrams 
are descriptive of a school in Toledo. 




z 



lU 

a 



104 THE SCHOOL BUILDINGS AND GROUNDS 

Laws on Building Requirements. — It is advisable for State 
legislatures to enact laws which shall specify what shall 
be the requirements under which new school buildings may 
be erected within its territory. A number of States have 
some provisions for such operations. 

The Pennsylvania school law has the following specifica- 
tions in relation to school buildings: 

Section 618. All school buildings hereafter built or 
rebuilt shall comply with the following conditions. 

In every school-room the total light area must equal at 
least 20 per cent, of the floor space, and the light shall 
not be admitted thereto from the front of seated pupils. 

Section 619. No board of school directors in this Com- 
monwealth shall use a common heating stove for the purpose 
of heating any school-room, unless such stove is in part 
enclosed within a shield or jacket made of galvanized iron, 
or other suitable material, and of sufficient height and so 
placed as to protect all pupils while seated at their desks 
from direct rays of heat. 

Section 620. No school-room or recitation-room shall 
be used in any public school which is not provided with 
ample means of ventilation and whose windows, when they 
are the only means of ventilation, shall not admit of ready 
adjustment both at the top and bottom, and which does 
not have some device to protect pupils from currents of 
cold air. Every school-room or recitation-room shall be 
furnished with a thermometer. 

Section 621. Every school building hereafter erected 
or reconstructed, whose cost shall exceed four thousand 
dollars ($4000), or which is more than one story high, 
shall be so heated and ventilated that each room and recita- 
tion-room shall be supplied with fresh air at the rate of not 
less than thirty cubic feet per minute for each pupil, and 



CONSTRUCTION OF SCHOOL BUILDINGS 105 

which air may be heated to an average temperature of 
seventy degrees Fahrenheit during zero weather. 

Section 622. All school buildings, two or more stories 
high, hereafter erected or leased in any school district of 
the first class in this Commonwealth shall be of the second, 
third, or fourth class, every building more than two stories 
high, thereafter built or leased for school purposes, shall 
be of fireproof construction. 

Section 623. All doors of entrance into any building 
more than one story high, used for a public school building 
in this Commonwealth, shall be made to open outward, 
and the board of school directors of every district in this 
Commonwealth shall, before the opening of the school term 
. next following the approval of this act, change the entrance 
doors of every such school building so that they shall all 
open outward. 

Section 624. In all school buildings more than one 
story high hereafter erected, all entrance doors as wSll as 
all doors from class-rooms, school-rooms, cloak-rooms or 
other rooms into halls shall open outward. 

Section 625. Every school building shall be provided with 
necessary fire-escapes and safety appliances as required by 
law. 

Section 626. The board of school directors in each school 
district shall put the grounds about every school building 
in a neat, proper, and sanitary condition, and so maintain 
the same; shall provide and maintain a proper number of 
shade trees. 

Site. — The site for erecting a school building requires 
more consideration in rural than urban districts. In rural 
districts the ground should be free from dampness, and if 
located on a hill the southerly side should be preferred, as 
it affords more sunlight and protection against winds from 



106 



THE SCHOOL BUILDINGS AND GROUNDS 



the north. Locations in level country should preferably 
have the corners of the building pointing north and south, 



Fig. 8 




School playground.- 



thereby affording sunlight for all sides at some part of the 
day. In cities the location should depend upon the school 



Til'^-^v 




108 THE SCHOOL BUILDINGS AND GROUNDS 

population of the neighborhood, and the school so placed 
as to be in the centre of the district. The available space 
should admit of ample playgrounds and be free from obstruc- 
tions from adjoining high buildings. One of the most impor- 
tant features should be air and sunlight, which is dependent 
upon the plan of construction and the surroundings. Good 
results are generally possible with V. U. T. H. E. L. or Y. 
shaped buildings. 

Playgrounds. — Playgrounds serve the double purpose of 
allowing space around a school for light and air, and furnish- 
ing the necessary means for the children to obtain exercise 
and pleasure out of doors. Every State should have a law 
forbidding the building of a school-house without suitable 
playgrounds. This may seem an unnecessary provision, 
as it seems scarcely plausible that a city would allow such 
an absurd thing as a school without a playground — yet it 
may occur. The size of the ground should be minimized 
by law. In Massachusetts it is limited to two acres; in 
England by rule of board, and in Germany there is required 
thirty square feet for every child using the school. 

Playgrounds should be suitably equipped for play and 
exercise for the children. They should be paved with 
brick, asphalt, or some material that can be readily cleaned. 
If space is sufficient, part may be used for experimental 
gardening and part for sand-piles, etc. 

Safety against Fire. — It is not generally known, but at 
least one hundred school-houses burn down every year. 
Therefore, every precaution should be taken to guard the 
safety of the pupils by sufficient doors in each class-room 
opening out into halls and on fire-escapes. Fire-proof 
buildings are desirable. As panic is more dangerous than 
the immediate effects of fire, frequent fire drills should be 
held to give confidence and discipline. 



CONSTRUCTION OF SCHOOL BUILDINGS 109 

Fire-escapes should preferably be located in a tower sepa- 
rated from the building. Smoke and flames shooting 
through windows around iron escapes fastened to the walls 
make them of little value. Interesting experiments have 
recently been made with chutes instead of steps for escape. 

Schools should be free from accumulations of refuse and 
inflammable material. Galvanized cans or a special fire- 
proof pit should be provided to hold ashes immediately 
after removal from the furnace. Ashes should be removed 
from the building at frequent intervals. 

It is a duty of the inspector to see that fire extinguishers 
are of an approved make, in working order, and placed 
where they can be seen and readily gotten at. All ex- 
tinguishers should be recharged every few months and the 
date of such action marked on a tag attached to the 
extinguisher. Teachers and older pupils should receive 
instructions in the use of fire apparatus. In cities, mjem- 
bers of the fire department should make regular systematic 
inspections of all schools, and recommend changes where 
needed. 

Plumbing and Drainage. — ^An ordinary school building 
is supplied with water-closets, urinals, sinks, washstands, 
drinking fountains, and boiler, making the plumbing at 
times intricate. The water-supply for closets and urinals 
may be taken from a reservoir or tank in or on the building. 
The street mains are usually constructed of cast iron with 
leaded joints, lead or wrought-iron service pipes bring the 
water-supply through the building, and lead pipes are 
attached to the various fixtures. All pipes should be 
located and protected when in exposed positions to 
prevent freezing in cold weather. 

The arrangement of pipes and appliances for drainage, or 
the removal of waste water and sewage, requires care and 



no THE SCHOOL BUILDINGS AND GROUNDS 

ingenuity, as faulty plumbing may be a menace to life. 
A complete barrier should be interposed against air currents 
working back through the pipes into the building. Traps 
and depressions containing a head of water are used for this 
purpose. Each fixture in the building should be properly 
trapped. Soil and vent pipes should receive special attention. 

Toilets and Urinals. — The inspector should in his investiga- 
tion of sanitation of building and grounds carefully inspect 
all water-closets and urinals; noting the location, condition 
of flush and ventilation, the number in relation to the school 
population, and the cleanliness of the room and basins. All 
traps and waste pipes should be effective to prevent odors. 
Where trough water-closets are used cleanliness and fre- 
quency of flushing should be noted. Out-houses should not 
be located too near class-rooms. There should be separate 
closets in each playground for both sexes and properly 
screened. Urinals should be constructed of slate or stone, 
properly flushed by constant running water. The slope 
should be sufficient to insure against stagnant pools. Soil 
pipes should be large to prevent being easily clogged up. 

Toilets and urinals in the building should be sufficient 
to meet the demands of the school population. They can 
be located in basement or on each floor, in which case they 
are best located in towers isolated from the class-rooms. 
Drainage, plumbing, and ventilation must be carefully con- 
sidered. Seats should be supplied suited for the younger 
children. 

Water-supply. — In order to determine the purity and suita- 
bility of water for household or drinking use, both chemical 
and bacteriological examinations are necessary. Chemical 
analysis shows the presence of organic and mineral impurity, 
such as accompanies infectious excreta from the intestines 
or bladder, also the presence of sewage. A bacteriological 



CONSTRUCTION OF SCHOOL BUILDINGS 111 

analysis shows the presence of bacteria, pathogenic or non- 
pathogenic. A chemical examination would show when a 
water is dangerous and liable to contamination from germs, 
and is an available safeguard even before bacteriological 
examinations show the presence of infection. 

In country or suburban districts, one must not be deceived 
by the clearness of the water, especially where the supply 
is from a well or spring, as there is always the possibility 
of infection from nearby or even distant sewage. 

Drinking Fountains and Cups. — In most of the large cities 
either by legislation or common sense, the public drinking 
bucket, cup, or spigot has been abolished. It has been 
proved to be a source of grave danger, spreading contagion 
that can be readily avoided. In the United States investi- 
gation shows that 25 per cent, of the cities have indi- 
vidual drinking cups and in 75 per cent, of their schools 
are sanitary drinking fountains. The following States 
have legislation forbidding the use of public drinking 
cups in school-houses: New Jersey, Wisconsin, Michigan, 
Kansas, Mississippi, Oklahoma, Massachusetts, Iowa, Cali- 
fornia, and Pennsylvania. There are also innumerable cities 
that through their Boards of Health have forbidden the 
use of these cups. 

The following is a statute in the State of Massachusetts: 

An Act 

To Restrict the Use of Common Drinking Cups. 

Be it enacted by the Senate and House of Representa- 
tives in General Court assembled, and by the authority of 
the same as follows : 

Section 1. In order to prevent the spread of communi- 
cable diseases, the State Board of Health is hereby authorized 



112 THE SCHOOL BUILDINGS AND GROUNDS 

to prohibit in such public places, vehicles, or buildings as 
it may designate the providing of a common drinking cup, 
and the board may establish rules and regulations for this 
purpose. 

Section 2. Whoever violates the provisions of this act, 
or any rule or regulation of the State Board of Health made 
under authority hereof, shall be deemed guilty of a mis- 
demeanor and be liable to a fine not exceeding twenty-five 
dollars for each offence. 

Section 3. All acts and parts of acts inconsistent here- 
with are hereby repealed. 

Section 4. This act shall take effect on the first day of 
October, nineteen hundred and ten. 

House of Representatives, April 7, 1910. 

Passed to be engrossed. 
Sent up for concurrence. 

James W. Kimball, Clerk. 

Wliere children must drink from the ordinary spigot 
without the aid of a cup, and the school authorities cannot 
be induced to install a sanitary drinking fountain, the safer 
plan is to turn the outlets up so the water is forced up and 
flows down over the opening. However, there is a very 
cheap sanitary arrangement that can be attached which 
replaces the old faucets. This arrangement, shown in the 
illustration, has been successfully tried out in Toledo's 
schools. It consists of a small glass cup with automatic 
cut off from which the child can drink without his lips 
touching the glass. Many different makes are marketed 
at various prices, but all are designed on the same prin- 
ciples. 



CONSTRUCTION OF SCHOOL BUILDINGS 



113 



Since the abolishing of the public drinking fountains and 
cups in several States and many cities, there have been placed 
on the market numerous inexpensive paper cups made of a 



Fig. 10 




Type of sanitary drinking fountain installed in schools by placing 
bubbling-cups on old fixtures. 



heavy bond or paraffined paper. Illustrations are here 
shown of some of these individual cups, also a simple method 
of making a cup from a square piece of paper. The pupils 
8 



114 THE SCHOOL BUILDINGS AND GROUNDS 

Fig. 11 




A Springfield drinking fountain. 
Fig. 12 




Paper cups. 



CONSTRUCTION OF SCHOOL BUILDINGS 



115 



can readily be taught how to make such cups and encouraged 
to use them on all occasions. 






B 




Individual cups made from squares of paper; easily taught to the 
children. 



Class-rooms. — Class-rooms should be large and cheerful 
and should seat not more than forty-five pupils to a room. 
The air space should be such as to allow not less than two 
hundred, and if possible three hundred, cubic feet per child. 



116 THE SCHOOL BUILDINGS AND GROUNDS 

Children are compelled to live five hours every day in these 
rooms, and it should not only be made inviting, but serve 
as an object lesson for healthful home living. Faulty 
lighting, ventilating or seating may directly cause many 
of the defects found among school children, and the school 
physician must be sure that school conditions are not 
responsible for the defects diagnosticated. 

Lighting. — Class-rooms in most buildings are lighted 
from three of the four points of the compass. The side not 
desired is the one giving no sunlight in winter. The east 
and west rooms are more desirable when it is only possible 
to use two sides. The amount of window area should be 
about one-fifth of floor space. Windows should not extend 
too near the floors, as the very low part is of little practical 
value. 

Artificial light is necessary in most class-rooms on dark 
days. Much has been written about various forms of arti- 
ficial lighting, but experiments in Chicago and Boston 
prove that direct lighting with ground-glass bulbs and reflec- 
tors situated high enough to diffuse the light is better than 
indirect lighting. There are, however, class-rooms in which 
mechanical work is taught where reflected light may be 
an advantage. Windows should be furnished with a light 
colored shade, which not only controls the direct rays of the 
sun, but by diffusing them aids in the lighting. The color 
of the wood-work and walls should be in light tints and the 
desks and other furnishings should be in harmony. A few 
appropriate pictures add cheerfulness and a finishing touch 
in the way of decoration. 

Dr. Myles Standish, of Harvard University, offers the 
following specifications for artificial lighting of school-rooms. 

1. The walls should be painted a very light color, prefer- 
ably an exceedingly pale green or buff. 



CONSTRUCTION OF SCHOOL BUILDINGS 117 

2. The wooden finish of room and desks should be light 
in color. 

3. The window shades should be able to exclude direct 
rays of sun, diffuse daylight freely, and also reflect a generous 
proportion of the light which falls upon them in the evening. 

4. Direct illumination is desirable. 

5. The lighting stations should be so arranged that no 
annoying shadows fall on the pupil's desk. 

6. .The newer forms of incandescent lamps and Zalinsky 
shades, when properly arranged, will give a candle foot 
illumination of 2.5 on each desk in the ordinary school-room. 

7. In most cities the expense of electricity used in the 
manner above described is not so much greater than the 
cost of gas. 

Lockers and Closets. — Where lockers and closets cannot 
be located in basement, arrangements can be made to place 
them alongside of class-rooms, with entrance from halls 
as well as rooms. A sufficient number of hooks should be 
provided to allow a separate hanger for each pupil. Where 
possible it is preferable to have separate lockers for each pupil. 

Cleanliness. — Cleanliness of school buildings from the 
viewpoint of the school inspector includes the absence of 
refuse, the dusting of rooms and furniture, and the cleaning 
of floors and playgrounds. Janitors, who depend upon 
political favor for their appointment are often very negli- 
gent in performing their duties. To inquire whether these 
caretakers use damp cloths for dusting, a vacuum cleaner, 
or a dust absorbing compound is of little importance. The 
question to solve is how often they use these implements 
and with what efficiency. An investigation of 1038 cities 
by the Child Hygiene Department of the Russell Sage 
Foundation showed that 643 claimed to use damp cloths 
for dusting, 894 dust absorbing compounds, and 87 cities 



118 THE SCHOOL BUILDINGS AND GROUNDS 

employ vacuum cleaners. However, the floors were washed 
and swept and windows cleaned at varying intervals. The 
most common practice seems to be once a month, often once 
in three or five months, and in some cities once a year. 

Inspection for cleanliness should not be confined to annual 
or biennial visits, but should be done frequently and always 
at a time unexpected by janitors. Observe conditions of 
cellars, toilets, and playgrounds. In recording presence of 
dust, due allowance should be made. for old dilapidated 
buildings where floors and walls create excessive dust 
from wear. 

Dust is harmful because it acts as an irritant to the mucous 
membrane, and assists in spreading infection. Every 
means should be employed to prevent its accumulation, 
and dissipation through the air. Dust may be lessened in 
schools by proper sanitary methods of cleaning, requiring 
pupils to wipe their feet before entering building, and using 
moist erasers for blackboards. Old floors can be oiled with 
advantage. 

School Furniture. — The relation of school furniture, desks 
and seats, to spinal curvature is briefly told in the chapter 
on "Orthopedic Defects." It emphasizes the great need for 
desks and seats built on scientific principles and the proper 
seating of school children. Dr. James Warren Sever, of 
Boston, has studied this important problem in the schools 
of the United States. He addressed inquiries to 230 school 
departments in cities with 250,000 population and over. 
Tabulated answers from 38 per cent, of these cities showed 
the following points of interest. 

1. The almost total uniformity of cities toward installa- 
tion of adjustable furniture. 

2. The large number of cities in which only a small per- 
centage of the total equipment is adjustable. 



CONSTRUCTION OF SCHOOL BUILDINGS 



110 



3. The use of the single desk and chair in place of the 
older form of double desks with settees and benches. 

4. The uniformity of the two types of adjustable furniture, 
namely, (A) The separate chair and desk (B) The automatic 
with settee seat. 

The inadequacy of the first type of chair back (No. 4 
[A]) and the faulty design of (No. 4 [B]) cause bad attitudes 



Fig. 14 



Fia. 15 





Showing unnecessary support 
above the hollow of the back; 
contributes to slouching. 



Showing chair and desk too small 
for a large child, which condition 
allows nothing but a bad posture. 



and must be uncomfortable. The seats slope too deeply 
backward, the backs vary considerably, and give support 
in the wrong place. The accompanying illustrations show 
the varieties of furniture most frequently used in the 
schools of the United States, and point out the good and 
bad features of each. 

While most of the large cities have installed some modern 
furniture, most of the rural districts still use benches that 



120 



THE SCHOOL BUILDINGS AND GROUNDS 



have the back and seat fastened to the desk behind, and in 
many places children are seated in ordinary kitchen chairs, 
or benches with no support for the back. 



Fig. 16 



Fig. 17 




These diagrams are intended to show clearly the position of the writing 
paper on the desk, the relative positions of arms, paper, and desk, and the 
direction in which the pen moves to secure uniform slant. Fig. 16 is the 
half side position mostly used in public schools and best adapted to them, 
because of the character of the desks. Fig. 17 is the square front position. 
In both diagrams, A represents the square turn at the right elbow and 
its position on the desk, B is the muscular rest of the forearm, C the position 
of the left hand in its relation to the paper and the right hand, D the pen- 
holder, and E E the imaginary line between the eyes along which the pen 
should travel in upward and downward strokes. 

With the right forearm crossing the lower edge of the paper a little to 
the right of the centre, the pen should progress one-fourth or one-third 
of the distance across a sheet of paper eight inches wide, before the position 
of the paper is changed. Always use the left hand to move the paper. 
Paper of this width should be shifted two or three times, and when the 
end of the line has been reached, the paper should be returned to its original 
position. Lift the pen before nioving the paper. 



Fig. 18 



Showing arrangement of seat to desk; i, plus distance; ii, minus 
distance; Hi, zero distance. 



There are on the market about 200 models of desks and 
chairs, most of which are poorly constructed, that give 



CONSTRUCTION OF SCHOOL BUILDINGS 121 

Fig. 19 




Chandler adjustable desk with the Boston chair. 
Fig. 20 




Boston school-house commission desk and chair, devised by Dr. F. J. 
Cotton. Good types of school desk and chair, also showing position of 
child in the chair. 



122 THE SCHOOL BUILDINGS AND GROUNDS 

either a faulty support to the back or none at all. The child 
is adjusted to the furniture and not the furniture to the 
child. In most of the seats it is impossible for a child to 



Fig. 21 




Fig. 22 




Faulty desks and chairs, stationary and non-adjustable. 



Fig. 23 




Adjustable desk and chair of steel; good type, but back of chair 
could be improved. 



CONSTRUCTION OF SCHOOL BUILDINGS 



123 



assume a comfortable and correct posture. Desks and chairs 
cannot be chosen for children according to grade in school 
or age of child. The height of the child must be the only 
consideration. This requires adjustable furniture. The 
desk and chair must not be too high or too low, nor too 
near or too far from each other. 

Fig. 24 




Adjustable Chandler desk and chair; good type, but back of 
chair could be improved. 



School desks must be adjustable to height, and there 
should be sufficient room below for the knees. It should be 
low enough for the elbow and forearm to rest comfortably 
on the desk without bending the back. The feet should rest 
flat on the floor and not dangle or be forced above the seat. 
The top should slope at an angle of ten to fifteen degrees, 
which will be comfortable and yet not allow the papers to 
slide off. 

The seat should be no wider than the hips, in depth two- 
thirds the length of the thigh, and should slope only slightly 
backward. The front edge of the seat should be about 



124 



THE SCHOOL BUILDINGS AND GROUNDS 



one inch behind the front edge of the desk. The construc- 
tion of the back of the chair is very important and should 
slope very slightly backward and support the spine in the 
lumbar region in all positions of the child. Any support 
above the hollow of the back is unnecessary, and tempts 



Fig. 25 



Fig. 26 





Fig. 27 



Fig. 28 





CONSTRUCTION OF SCHOOL BUILDINGS 
Fig. 29 



125 




Figs. 25 to 29. Some types of adjustable desks and chairs with 
various defects. 



Fig. 30 




Adjustable school seat. (Miller and Stone.) 



126 THE SCHOOL BUILDINGS AND GROUNDS 

slouching positions. Desks and chairs adjustable in all 
directions are complicated, require considerable care, and 
have no special advantages. The chair may have one or 
two cross-bars, providing they are not higher than the lower 
part of the shoulder-blades. An adjustable cross-bar is 
an advantage, and should be convex forward and concave 
from side to side to fit the lumbar curve. 

Single desks and chairs should be preferred. Benches, 
kitchen chairs, and settees are distinctly bad. 

At the beginning of each school term the medical inspector 
should make a careful inspection of the furniture as adjusted 
to each child in the school he visits. He should also urge 
frequent rest periods to protect the children against fatigue. 
Most cities have some arrangement for physical exercise 
for the pupils, which is a most valuable adjunct in the pre- 
vention of spinal deformities. 

Ventilation and Heating. — Pure air in the class-rooms has 
an important bearing on the health and vitality of the pupils 
who are required to spend several hours daily indoors. By 
pure air is meant air having the required component parts 
of oxygen, nitrogen, argon, carbonic acid, and aqueous 
vapor. The carbonic acid, which is conceded to be one of 
the most variable factors and the deleterious product, should 
not exceed 0.04 per cent, in the volumetric composition. 
In schools as in other dwellings, various foreign particles, 
including some that may be infectious, are carried in the air. 

The air may become vitiated by the respiration of the 
children and teacher, by combustion of coal and gas, by 
fermentation and putrefaction of animal or vegetable 
organic matter, by dried excreta and dust from chalk, 
blackboards, slates, wear of floors, and furniture. 

The average individual breathes at the rate of seventeen 
respirations per minute. At each respiration 500 c.c. 



CONSTRUCTION OF SCHOOL BUILDINGS 127 

(30.5 cubic inches) of air pass in and out of the lungs. 
In its passage through the kings the air loses 4 to 5 
per cent, of its oxygen, and when exhaled this volume in 
carbonic acid is added. The amount of aqueous vapor is 
increased, the temperature is elevated to that of the blood, 
98.2° F., and there is added considerable putrefiable organic 
matters. The kind and quantities of these organic matters 
vary with individuals, their cleanliness and state of health. 
Germs of communicable diseases located in the respiratory 
tract of a child are added to the exhaled matter. These 
germs and dust particles inhaled in respiration adhere to the 
moist mucous membranes of the nose, throat, and mouth, 
and some may later reach the lungs, if not again exhaled 
or removed by the secretions of these organs. The purity 
of the air depends upon the efhciencj^ of the installation 
which controls the entrance of fresh air and exit of the foul 
or vitiated air. The process of this circulation bf air is 
known as ventilation. 

Ventilation may be (1) natural or (2) artificial. One 
should also consider an "internal" ventilation referring to 
the ventilating of the buildings and "external" or the diffu- 
sion of the atmosphere around the building. The latter is 
rarely taken into consideration, but of primary importance. 
The width of the streets, and the distance between buildings 
as well as the height of neighboring structures influence 
the atmosphere outside. Drainage, sewerage, refuse, and 
decaying animal or vegetable matter may vitiate the sur- 
rounding air as well as that of the building. This is so in 
ventilation where the air is forced from the outside through 
the building. 

Direct or natural ventilation is due to (1) the action of 
winds, and (2) diffusion of gases of unequal densities and 
temperature. Buildings receive the effect of these forces 



128 THE SCHOOL BUILDINGS AND GROUNDS 

through open windows, doors, and chimneys, and through 
porous structures or loose fittings. 

In the artificial methods, air is forced through a building 
by means of fans. This air may be heated over hot-water 
pipes or by steam. The impure air is removed from the 
building by extraction. The column of air in the outlet 
or extraction shaft is set in motion by various systems of 
heating the air, and can be increased by creating a vacuum 
in the upper part of the flue by the use of ventilating cowls. 
Care must be taken that the process of heating the air does 
not produce a dry, hot air by lowering the humidity. This 
can be avoided by humidifying the air with live steam 
before it reaches the rooms. 

Ventilation has always been a vexing problem that has 
produced many ideas and plans, some simple, some intricate, 
but practically all are imperfect from one cause or another 
in practice. Some prefer the plenum system, others a gravity 
system, but whatever the system it is to some extent 
dependent upon the janitor for regulation, and therefore 
requires some intelligence and skill and most important, 
common-sense. It must also be borne in mind that the ther- 
mometer is not the only gauge to ventilation and heating, 
as humidity plays an equally important function. These 
are phases which at present are being investigated, and not 
as yet thoroughly understood. It remains, however, to be 
said, with our present knowledge of ventilation, nothing can 
surpass the direct ventilation from open windows. There 
should be a complete change of air every eight minutes. 
A class-room for forty-two pupils should be twenty by thirty 
feet, with a ceiling height of at least twelve feet, and in 
buildings with little open space around them, a fifteen-foot 
ceiling is more desirable. 

Heating, closely allied to ventilation, is a serious problem 



CONSTRUCTION OF SCHOOL BUILDINGS 129 

in the schools. The ancient coal stove cooked the child 
nearest to it on one side and froze him on the other, while 
the other pupils experienced varying degrees of discomfort. 
Direct hot air from furnaces was almost as unsanitary. 
More modern heating plants which take fresh air from the 
outside and force the heated air through radiators, auto- 
matically controlled, are more desirable. 

There is little doubt that not only the temperature of the 
room but the amount of vapor or humidity affects the grade 
of scholarship. Every class-room should be equipped with 
a thermostat and a thermometer, which should be critically 
observed by the medical inspector at frequent intervals The 
inspector should never take the opinion of a teacher as to 
the effectiveness of the ventilation and heating, for the reason 
that people working in a room become accustomed to odors 
and unconscious of ill-ventilation. In his records, the phy- 
sician should calculate the amount of cubic space "allowed 
each child in a class-room, and each room should be estimated 
separately, noting the size and ejBBciency of inlets and out- 
lets to the system. The inlet can be told from outlet by 
watching the direction of a candle flame held before the 
opening. There exist instruments (anemometers) for the pur- 
pose of measuring the velocity of ingress or exit of the air, 
which are valuable where a scientific study is being conducted. 

The inlet should be located a few feet above the floor 
and should cause no unpleasant draughts or dust. Outlets 
should be as high as possible and close to the ceiling. The 
relation of inlets and outlets should be such as to cause the 
air passing from one to the other to mix with the atmosphere. 

The temperature of class-rooms should not be allowed 
to go above 68° F. during days when the building is arti- 
ficially heated. A temperature of about 65° F. is to be 
preferred, as the mind and body seem to work better at 
9 



130 THE SCHOOL BUILDINGS AND GROUNDS 

this figure. Thermometers should be placed about four feet 
above the floor and not against walls or partitions that 
admit of radiation and false readings. When the pupils are 
at recess, windows should be opened wide. 

The relative humidity of a school-room should be near 
50 per cent., and should not be allowed to drop below 40. 
The complaint of teachers to window or wall sweating is 
erroneous, as it is an advantage in many cases. Rooms 
where no air currents exist, are sure^ to be hot and dry. 
These air currents are necessary both winter and summer. 

Systems of mechanical ventilation depend on the use of 
blowers or exhaust fans; the former is known as the "plenum" 
system and the latter the "vacuum." In the plenum system 
the air is drawn into a box and by revolving fans blown 
through a conduit into the building. When desired, the 
air may be passed through a chamber to heat it before enter- 
ing the rooms. The vacuum system is just the reverse of 
this and consists in drawing the air from the rooms through 
conduits by means of exhaust fans and discharging ' in the 
open. The plenum system is less expensive, as it does not 
draw away the heated air so quickly, and more practical 
because it avoids draughts. 

Care must be taken, however, as to the source of air 
used, also the filtering. 

The heating of a building may be by direct radiation, 
such as open fires or stoves; by conduction, as furnaces, and 
by convection, as exists in circulating steam or hot water 
passing through pipes and radiators. The method to be 
adopted depends largely upon the space to be heated, the 
smaller the space the simpler the method required. Hot 
water and steam pipes are more suitable for large buildings, 
and are of the "direct" or "indirect" method. The "direct" 
method has separate heating surfaces in each room; the 



< 




COLD-ROOM AND OPEN-AIR SCHOOLS 131 

"indirect" concentrates the heating surface in a compart- 
ment in the basement and distributes to the various rooms 
through conduits. . 



COLD-ROOM AND OPEN-AIR SCHOOLS. 

If we wish to prevent tuberculosis and mahiutrition in 
children, plenty of pure fresh air and nourishing food are 
needed. The child who is tuberculous or is likely to be- 
come so by reason of a predisposition inherited or acquired, 
requires our special attention on the question of fresh air; 
but we should not wait for a child to reach this precarious 
condition. All children should receive the benefits of fresh, 
pure air while at school. 

For the physically deficient child, there can be adopted 
(1) cold-room schools or (2) open-air schools. 

1. Cold-room schools are adapted for cases of malnutri- 
tion, anemia, pale and physically undeveloped pupils, 
children with enlarged glands, not tuberculous, enlarged 
tonsils, and adenoids. These cold-room classes can be 
organized in any school building. The windows are kept 
wide open, the air diverted by screens, and the children wear 
the ordinary street wraps and gloves. The temperature 
is maintained between 50° and 60° F. Several periods of 
the session are devoted to some form of exercise which 
necessitates moving about the room, but no time is allowed 
for recess or lunch. 

2. There are various types of open-air schools (Plates 
III and IV) to be found both in Europe and this country. 
In Germany there are the " Waldschulen," or forest schools, 
which are feasible during the summer months or in a tem- 
perate climate. Chicago has a similar institution in the 
"Outing Camp at Algonquin," which is somewhat like the 
vacation country homes. 



132 



THE SCHOOL BUILDINGS AND GROUNDS 



The two common types of fresh air schools used in this 
country are the open-air class-rooms built on the roof of a 
school or other institution, and temporary structures with 
a roof, flooring, and sufficient sides to protect against wind 
and weather, built in the open. 

There are fifty-five open-air classes in the United States 
accommodating 1755 pupils. The following cities have 
such institutions: 



List of Open-air Schools in the United States. 



City. 
Monrovia, Cal. . 
Oakland, Cal. 
Colorado Springs, Colo. 
Denver, Colo. . 
Hartford, Conn. 
South Manchester, Conn. 
Washington, D. C. . 
Chicago, 111. 



Chicago, 111. 
New Orleans, La. 
Boston, Mass. . 
Cambridge, Mass 
Grand Rapids, Mich 
St. Paul, Minn. 
Montclair, N. J. 
Newark, N. J. . 
Orange, N. J. 
Albany, N. Y. . 
Buffalo, N. Y. . 
Schenectady, N. Y 
New York City 
Rochester, N. Y. 
Syracuse, N. Y. 
Cincinnati, Ohio 
Cincinnati, Ohio 
Columbus, Ohio 
Hazleton, Pa. 
Mt. Airy, Pa. . 
Philadelphia, Pa. 
Pittsburgh, Pa. . 
Williamsport, Pa. 
Pawtucket, R. I. 
Providence, R. I. 
Kenosha, Wis. . 



No. of schools and classes. 

1 

1 
(Not yet in operation) 
(Not yet in operation) 

1 

1 

1 
Tuberculosis Institute School 
(three or four extra schools 
during summer months) 

6 

2_ 
5 class-rooms 

1 

2 
(Not yet in operation) 

1 

1 

2 

1 

1 

(Not yet in operation) 

12 

1 
(Not yet in operation) 

2 

1 open-air room 

(2 schools projected) 

1 

1 

3 

2 
(Not yet in operation) 

1 

1 



No. of 
pupUs. 

25 



25 
20 
35 



2501 

160 

100 

30 

40» 

21 
30 
43 
25 
20 

526 
30 

40 
35 

40 
30 

751 
75 

25 
25 
30 



Approximate. 



COLD-ROOM AND OPEN-AIR SCHOOLS 133 

There can be little doubt as to the value of these fresh- 
air classes. Any child whether inclined to tuberculosis or 
not will be benefited. These classes have a special curric- 
ulum which includes plenty of exercise and rest periods, 
and the children are furnished with lunches of nourishing 
food. To assure maximum and permanent results require 
a study of the home and social conditions of the pupils, 
and remedial measures to prevent the undoing of good 
accomplished at the open-air schools. While at school 
the children are protected against cold by wearing wraps, 
caps, and mits, and when needed, blankets are wrapped 
around the legs. Under such care, pupils rarely complain 
of any discomfort from low temperature. 



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PART III. 

CONTAGIOUS, Al 
CABLE DISEASES. 



IKFECTIOUS, CONTAGIOUS, AND COMMUNI- 



GENERAL CONSIDERATIONS. 

Medical inspection was first introduced into the schools 
for the purpose of preventing the spread of infectious dis- 
eases, and even today in a number of cities the qniy duties 
of the physicians are to protect the pupils from contagion. 
Many cities are indebted for their school inspection to an 
epidemic of some infectious disease which played havoc in 
the schools. There are 1285 cities in the United States 
that have organized systems of graded public schools under 
superintendents; 443 have systems of medical inspection, 
while 405 of this number inspect for the detection of con- 
tagious diseases. Only 214 of the cities claim to make 
complete physical examinations through school physicians. 

The contagious diseases found among school children are 
the major infectious diseases or exanthemas and the minor 
contagious skin and eye diseases. The infectious diseases, 
like scarlet fever, diphtheria, measles, and smallpox, are 
of first importance to the medical inspector, because they 
are extremely dangerous and often fatal. The contagious 
skin diseases may cause an epidemic and inconvenience 
those afflicted, but are not detrimental to life. The duty 



136 INFECTIOUS AND COMMUNICABLE DISEASES 

of the school physician is to diagnosticate all cases and 
exclude those which are dangerous in the class-room. 

Either by statute, or by rules and regulations of health 
or educational departments, the school doctors are forbidden 
to treat any defect or disease among the pupils of the schools 
under their charge. lii this study of diseases and defects, 
treatment is therefore omitted, except prophylactic treat- 
ment, insofar as it concerns the work of the medical in- 
spector. The medical work of the school physician deals 
primarily with diagnosis; therefore, more consideration is 
given to this subject. The success of the inspectors in pre- 
venting the spread of contagion is largely dependent upon 
accuracy in diagnosis; therefore, health departments should 
place at the disposal of their school physicians every oppor- 
tunity for a thorough training in the recognition of the com- 
mon contagious diseases at a contagious disease hospital. The 
physician does not have the advantage he would in private 
practice in that all cases of a suspicious nature found in a 
school must be diagnosticated at once, as delay is dangerous. 
At a home, if the attending physician is in doubt, he may 
isolate the child for a day or so and watch developments 
before giving a final diagnosis. In school the physician 
is not allowed this privilege. Therefore, it behooves the 
physician who contemplates school-work to become expert 
in physical diagnosis. Even then a well- trained physician 
will meet with occasions when the signs and symptoms are 
so atypical or masked, that a diagnosis is impossible and 
the services of an expert are required. 

It is well for a city to have in connection with the corps 
of medical inspectors one or more diagnosticians, physicians 
expert in the diagnosis of contagious diseases, to whom all 
cases of doubtful diagnosis can be referred. Philadelphia 
has four diagnosticians. 



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GENERAL CONSIDERATIONS 137 

Certain rules should be observed in the finding of con- 
tagious diseases among school children for the purpose of 
safeguarding the other pupils as well as the community. 
As this subject is important some space in the succeeding 
pages is employed to indicate what action the inspector 
should take when he finds a contagious disease at 
school. 

Prevalence of Contagion among Children. — The so-called 
children's contagious diseases are not only more common 
among children than adults, but also more fatal. Scarlet 
fever, for instance, is eight times more fatal among children 
and 90 per cent, of the deaths from diphtheria occur under 
the age of ten years, thereby making the schools the greatest 
camping ground for contagious diseases. Besides the ordi- 
nary, typical, and easily recognizable cases there may be 
mild ones difiicult to diagnosticate, including convalescents 
who have been released too soon; those who have crimi- 
nally concealed their contagion and returned to school with- 
out having exercised any precautions; and the contact 
cases, or those who have illness at home or in one way or 
another have been exposed to contagion. There are also 
normal people, who may carry pathogenic germs in their 
throats. 

Kirchner, from an investigation in Prussia, has shown 
that in the first year of life, whooping cough, measles, and 
diphtheria are the prevalent contagions. In the second 
year, measles, diphtheria, whooping cough, and scarlet 
fever head the list in the mortality rate, and tuberculosis 
occupies fifth place. From the third to the fifth year tuber- 
culosis occupies fourth place, sixth to the tenth year third 
place, and from the eleventh year on, first place. These 
statements were corroborated by investigations in the 
United States by Dr. Samuel G. Dixon. 



138 INFECTIOUS AND COMMUNICABLE DISEASES 

All children who are known to belong to families having 
consumption or who live in a house where the disease exists 
should be examined by expert diagnosticians immediately 
upon development of a persistent cough or evidence of 
general failure of health and strength. When a case of 
tuberculosis is found the questions of early treatment and 
the advisability of exclusion are important for the consid- 
eration of the medical inspector. 

Use of Terms. — ^The following terms in use are more or 
less confusing to both physician and layman: "infection," 
"contagion," "communicable," "transmissible." 

An "infectious disease" is one due to a special organism, 
and may be transmitted to others through various channels. 
All infections are not contagious. Typhoid fever, for 
instance, is an infection but not a contagion, 

A "contagious disease" is one that is transmitted from 
sick to well by contact. This term is more often used to 
designate the eruptive fevers, where recognition is based 
on a period of incubation, mode of onset, clinical course, 
and a respective eruption which is peculiar to that disease. 
These are smallpox, varicella, measles, rubella, and scarlet 
fever. 

A "communicable" or "transmissible" disease is one which 
can be conveyed to another. It may or may not be due to 
a specific microorganism, and it is not necessary to have 
actual contact with a previous case. Rabies is a transmis- 
sible disease but not a contagion; malaria is transmissible 
through the mosquito, but cannot occur from contact with 
one suffering with the disease. 

A "specific infection" is one due to a special micro- 
organism common to that disease only. These diseases 
breed their own kind, as in the tubercle bacilli, causing 
tuberculosis and no other infection. 



GENERAL CONSIDERATIONS 139 

Methods of Transmission. — ^The methods of transmission of 
infection from the sick to the well are: 

1. Direct contact with sick. 

2. Through the air. 

3. Germs adhering to clothing, furniture, or other 

articles. 

4. Infection of food and drink. 

5. Insects, such as flies and mosquitoes. 

6. Infected earth, as in tetanus. 

7. Domestic animals. 

Bacteria may gain entrance into the body and infect 
through the following channels: 

1. The digestive tract. Microorganisms may gain 
entrance to the system with food or drink, as may occur 
with typhoid fever, tuberculosis, and dysentery. 

2. The respiratory tract: tuberculosis, pneuinonia, and 
influenza are examples. 

3. The skin. It is doubtful whether the unbroken skin 
can admit bacteria. When this apparently takes place 
there is probably a wound so small as to be practically 
invisible. The skin is the channel of infection in rabies 
and tetanus. Tetanus is a form of "intoxication" in which 
the germs remain at the seat of the wound and there form 
toxins which enter the system. 

4. Heredity. There is no doubt of the transmission of 
infection to the fetus. This may be from either parent, 
at the time of conception, as in syphilis, or at a later period 
from the mother. Smallpox, measles, pneumonia, scarlet 
fever, tuberculosis, and other diseases are capable of such 
transmission. 

Methods of Detection of Infection. — It is physically impos- 
sible for a physician to examine each pupil daily, and even 
were it possible, a child who presented no suspicious symp- 



140 INFECTIOUS AND COMMUNICABLE DISEASES 

toms upon examination might within a few hours have 
marked signs of a contagious disease. One of the chief 
means for detecting cases in school is the alert, instructed 
teacher who sends every child with the least suspicion of 
an acute illness to the medical inspector for a diagnosis. 
By "instructed teacher" is meant one who can recognize 
the common signs of prevalent diseases, such as in a 
child vomiting, the possibility of its being a symptom 
of one of the acute infections instead of passing it by as a 
simple case of indigestion. She will also notice and under- 
stand the usual bright, attentive child who suddenly becomes 
languid and "heavy-eyed," flushed, and feverish-looking is 
a case for inspection bv the school doctor. 

The medical inspector may aid in keeping his schools 
clear of epidemics and at the same time interest the teachers 
to cooperate by occasional lectures on the diseases of child- 
hood. The health department can also help by issuing 
"A Circular of Instructions for Teachers" which should 
tell which children to send to medical inspectors and why. 

Class-room inspections by allowing the pupils to pass 
in front of the doctor while standing with his back to a 
window takes but a few moments and often nets one or more 
cases of contagion. This is also the best method to adopt 
when a case has been found and it is desired to trace any 
possible contact cases. If it was diphtheria, the throat of 
every child in the school can be inspected and suspicious 
throats cultured. If scarlet fever was found, the doctor 
should examine the face and hands of every child for peeling 
of the skin. The author has on several occasions entered 
a school just when recess was over, and standing at the head 
of the stairs isolated a case of contagion, while the children 
filed up to their class-rooms. 

All pupils who are absent from school for three or more 



GENERAL CONSIDERATIONS 141 

days without bringing a written excuse, and, if ill, a certifi- 
cate from the attending physician, should not be allowed 
to take their seats in the class-room until passed upon by 
the inspector. 

The nurse while assisting the teacher or the doctor in 
preliminary examinations may occasionally detect a sus- 
picious case which should be referred to the physician. 

Some of the subacute or chronic infections, especially 
of the skin, such as scabies, favus, and trachoma, are often 
detected while making a complete physical examination. 

Action Taken by Medical Inspector upon the Detection of 
a Case of Contagion in Class-room. — A pupil suffering from a 
contagious disease, even when it is a latent or extremely 
mild case, should be immediately excluded from the school, 
and instructed to go home and not linger around the school 
yard or neighborhood. The child is given a special card, 
stating the disease suspected and ordering the parents to 
consult a physician. 

The central office of the Bureau of Health is notified by 
telephone the name and address of pupil, the location of 
school and disease found. This telephone message is verified 
by a postal designed for reporting transmissible diseases. 

The Medical Inspector should then make a class-room 
inspection in the room occupied by the infected child. This 
class is then dismissed for the day if the disease is scarlet 
fever, diphtheria, or smallpox. If the case is found in the 
morning the entire school can be dismissed at the end of 
this session to admit of disinfection during the afternoon 
hours. This procedure allows the janitor to open the windows 
in the evening after eight hours' action of disinfectant, and 
makes it possible to resume school the following morning. 
Instructions for such action should come through the Super- 
intendent of Education or his assistants. 



142 INFECTIOUS AND COMMUNICABLE DISEASES 

The office records should be consulted to see if any other 
member of the same family or persons living in the same 
house are attending that school, and, if so, such children 
should be excluded as "contact cases." Further action 
at the home of the pupil is a responsibility of the health 
department and its division of contagious diseases. 

If the case found is measles, rubella, varicella, mumps, or 
whooping cough, the child should be excluded and the class 
inspected for more cases. The school, however, need not 
be closed for disinfection, but the health department should 
be notified in the usual manner. If a number of successive 
cases are found in the same school, the following week-end 
holiday or an intervening legal holiday can be utilized to dis- 
infect the building. This method prevents an unnecessary 
interference with the school-work. 

If a child suffering from diphtheria is found in the class- 
room, it may be advisable to take a culture from the throats 
of the children seated nearest to him. In all cases, however, 
a culture should be made of the cases diagnosticated. This 
may prove of value in cases of disputed diagnosis. 

If scarlet fever has been found, the inspection should 
include the hands and face of the pupils for possible peeling 
of skin, also marked erythema of the throat. Teachers in 
class-rooms where cases have been found should be instructed 
to be on the watch for suspicious cases. 

Exclusions and Quarantine. — When the school inspector is 
doubtful of his diagnosis in a suspicious case of contagion, 
he should exclude the child and by telephone notify the 
health department that he has excluded a suspicious case 
and desires the diagnosis of the contagious disease inspector 
or one of the consultants. Philadelphia maintains four 
diagnosticians or experts on contagions diseases for such 
diagnosis. 



GENERAL CONSIDERATIONS 143 

In all cases where a child is excluded, principal and teacher 
should be notified and a record made on blanks furnished. 
The quarantine of the home of the pupil and after care is 
the duty of the health department through its corps of 
contagious disease inspectors. 

It is the duty of the school medical officer to know the 
period of exclusion for the various transmissible diseases, 
as prescribed by statute or by rules and regulation of the 
health department and the board of education. In some 
cities these periods vary according to rules of the board of 
education or State laws. 

When the children excluded are permitted to return to 
school, the principal should receive from the medical in- 
spector a printed postal stating the date of return, ancj he 
should send a second postal to notify the child's family. 

Department of Public Health and Charities. 

BUREAU OF health, ROOM 712, CITY HALL. 

Philadelphia, 191.— 

To the Principal of 

School. 

Exclude from School all persons residing with the family of 

No :,___.! Street, who is suffering with 

, until a Medical Inspector certifies that the period 

of exclusion has ended. 

The folloioing persons attend your school . 

By order of the Board of Health. 



p Chief Medical Inspector. 

Medical Inspector. 



144 INFECTIOUS AND COMMUNICABLE DISEASES 

Department of Public Health and Charities. 

BUREAU OF health, ROOM 712, CITY HALL. 

Philadelphia, 191-— 

To the Principal of 

-— — - —.School. 

The period of exclusion from school of all persons residing 
with the family of ^ 

- --. No.— - .....Street, 

who has been suffering from ^ having expired, said 

persons are permitted to return to school on 

By order of the Board of Health. 

Per Chief Medical Inspector, 

Medical Inspector. 

Bureau of Health, 
city hall. 

Philadelphia, __ ..191-.. 

Sir: 

You are hereby notified that notice has been sent 

to School, permitting the 

return of your child on.... 

Per 

Medical Inspector. Chief Medical Inspector. 

Periods of Exclusion Prescribed by the Legislature of 
Pennsylvania. — "No child or other person, suffering from 
anthrax, bubonic plague, cerebrospinal meningitis (epidemic), 
cerebrospinal fever (spotted fever), asiatic cholera, small- 
pox (variola, varioloid), typhoid fever, yellow fever, relajtsing 



GENERAL CONSIDERATIONS 145 

fever, or leprosy, or residing in the same premises with 
any person suffering from any of said diseases, shall be per- 
mitted to attend any public, private, parochial, Sunday, or 
other school, etc. Such exclusion to continue for a period 
of thirty days following the release, by reason of the recovery 
or death, of the person last afflicted in said premises; or 
his or her removal to a hospital, the removal of quarantine 
and thorough disinfection of the premises. 

Scarlet Fever (Scarlatina, Scarlet Rash). — The period of 
exclusion is thirty days following the removal of quaran- 
tine and the disinfection of the premises wherein such 
child or other person resides. If the person afflicted has 
not been properly isolated during the quarantine period, 
such exclusion period shall continue for ten days. n 

Diphtheria. — The period of exclusion from school of a 
child suffering from diphtheria and all other children in the 
same premises is twenty-one days from the date of onset 
of the disease in the last person afflicted; or fourteen days 
from date of onset provided that antitoxin has been used 
for the treatment of the person or persons so afflicted, and 
the inmates. And further provided, that two negative bac- 
teriological cultures have been secured from the diseased 
area of the person last so afflicted, on two successive 
days. The children may then be readmitted to school 
after the removal of quarantine and disinfection of the 
premises. 

Mumps, Measles, German Measles, or Chickenpox.- — For 
these diseases the period of exclusion shall be twenty-one 
days from the date of reporting the case, and disinfec- 
tion of premises, except when any of the inmates not 
afflicted after thorough disinfection of clothing shall take 
residence in other premises, the period of exclusion shall be 
fourteen days from such removal. 
10 



146 INFECTIOUS AND COMMUNICABLE DISEASES 

Whooping Cough and Erysipelas. — Cases are to be ex- 
cluded for a period of thirty days. 

By rule of the Bureau of Health, in contagious diseases, 
persons can leave a quarantined house only after an anti- 
septic bath and disinfection of clothing, and they must not 
return to the infected house. Where this rule is disobeyed, 
the entire house to which they move is disinfected and all 
school children in such premises are excluded from school 
two weeks. 

Placards. — In Philadelphia, the following contagious dis- 
eases are placarded — diphtheria, scarlet fever, smallpox, 
measles, typhoid fever, cerebrospinal meningitis, anthrax, 
anterior poliomyelitis, and glanders. Yellow placards 
with black letters are used in all cases except measles, 
typhoid fever, anterior poliomyelitis, and cerebrospinal 
meningitis, when white placards with black letters are 
used. 

Placards must be placed upon the front and rear entrances 
to the building and remain there until the case is terminated 
by death or recovery, and the house has been disinfected 
by the Bureau of Health. 

When a contagious disease occurs in an apartment house, 
or where more than one family occupies a dwelling, the 
entrances to the building must be placarded, not the apart- 
ment where the case is confined. 

As a rule, families with contagion in the household can 
be trusted to observe the rules of the health department 
to prevent spread of the contagion. In these cases, placards 
and general supervision is all that is necessary, but where 
rules are disobeyed and carelessness exists, the case should 
be removed to a hospital for contagious diseases or the 
home quarantined with police officers on guard. 



GENERAL CONSIDERATIONS 147 

Scarlet Fever. 

All persons not occupants of this house are notified of 
the presence of scarlet fever in it, and are warned not to 
enter it until this notice is removed. The person sick with 
scarlet fever must not leave the house as long so this notice 
remains here. 

Notice to the Milkman. 

Milk dealers must not remove bottles from premises 
where any contagious disease exists without permission 
from the Bureau of Health. 

By order of 

The Board of Health. 

The Act of Assembly, approved May 14, 1909, provides 
that the removal, defacement, covering up, or destruction 
of this placard shall be punished by a fine of not more 
than SI 00 or by imprisonment of not more than thirty days, 
or by both. 

Disinfection. — Disinfection of schools as in other buildings 
consists in closing all windows and doors, all openings and 
cracks with glued paper, and liberally sprinkling on the 
floors, formalin alone or mixed with other drugs to increase 
its effectiveness. The building should remain closed for 
at least eight hours after disinfection. The janitor should 
be previously notified to remove from the rooms all plants 
and aquaria. 

An interesting investigation by Dr. W. R. Stokes and Dr. 
H. W. Stoner, of Baltimore, on the efiiciency of formalde- 



148 INFECTIOUS AND COMMUNICABLE DISEASES 

hyde gas in preventing the spread of communicable diseases, 
shows that formahn permanganate method requires the use 
of 300 c.c. of formahn for every 1000 cubic feet of air space. 
They also found that the efficacy of disinfection is increased 
by a high relative humidity and in any event must not be 
lower than 60 per cent, or the disinfection is unsatisfac- 
tory. This is also the case if the temperature is below 65° F. 
A method of disinfection known as the formalin-aluminum 
sulphate-lime method is prepared as follows: Mix twenty 
to twenty-five pounds of commercial aluminum sulphate 
in five gallons of hot water, which is mixed in turn with 
fifteen gallons of formalin; 300 c.c. of the aluminum sul- 
phate solution is mixed with 600 c.c. of formalin; 2000 
grains of unslaked lime is placed in a large bucket and the 
solution poured over it. This causes a rapid evaporation 
of the formaldehyde gas with moisture. The experiments 
prove the destruction, if humidity is above 65 per cent., of 
non-spore-bearing organisms as Bacillus coli. Bacillus pyo- 
cyaneus and typhosus, also the Bacillus tuberculosis. 

Absentees and Contagion. — Every child who is absent from 
school for a number of days should be carefully examined for 
signs of peeling or discharges from ears or nose. These 
signs are more significant if the child vomited on the day 
before absence. 

To avoid contagion from diphtheria, cultures should be 
made from the throats of these absent pupils upon return, 
and any bacteriological evidence of diphtheria should be 
ample cause to exclude the child. The dangers from diph- 
theria carriers should be always kept in mind, and every 
precaution taken to prevent contagion. 

The importance of examining children absenting them- 
selves for several days is shown by the following report 
from New York City: 



'A 


> 


Ph 


TtT 


M 


H 


O 


m 


o 


^ 



Oi 

o 

Oi 
1-1 


pnoniqoi'a; 


00 <M -^ (N "5 CO tH 

,-1 O lO i-H 


05 
(N 


snaan^ 


rH (N CO O O lO • 

,-1 ^ rH . 


00 


uApiooja 


OS T-l CO CO ■* 1> • 

1-1 00 ^ ■* CO CO • 

tH (M 1-1 1-1 • 


o 

CO 

rH 


xuojg aqx 


(M ^ lO 1> t^ <N • 

1-1 rt< Tt< (M (N • 




1-1 rt CO CO ■«*• oi cq 
nB^'^'BquBp\[ ^ °^ ^ ^ ;2 ^ 


05 
O 
CO 
r-T 


AlO 3iJO^ AiajN^ 


^ ^- -rt* ■* 1> CO CO 

^» o 05 -^ CO iH 

(N !-(_ 1> CO CO 


o 

05 


o 
I-l 


puouiqoiy; 


i-H O 1-1 O ^ l> — 1 
rH (N 00 rH O 1-1 
T-( I-l 


I-l 
CO 


suaan^ 


CO 00 CO CO 1-1 (N 
CO rH 


03 


uAjJiooja; 


lO (N OS O 05 ^ • 
1-1 CO 1-1 <M t^ CO • 
1-1 CD (N 1-1 


05 
IN 


xaojg: aqx 


(N l> 00 00 •* iH • 

i-( (M rH 


O 


U'B;^^'BI{U'BJ\[ 


O O O 00 O 05 • 
Tt^ -# (N O) CO lO ■ 

iH lO IM IH iH 


00 


^*I0 ^Jo^ Avaj^ 


1-1 rH O Ol lO CO iH 
l> t^ 00 lO iH Tjf 

CO <N CO ^ (M 


CO 
00 

!N 


05 


pnoraqoi'jj 


t^ CO 05 iH rH CO N 
CO 1-1 rH 
rH 


05 

o 

(N 


SU88nJ5 


• CO (N CO • Ti< ■ 


lO 


Ui^pfooag 


lO lO ■^ CO CO ■^ U3 
(M CO (M <N t^ CO 

rH CO CO rH rH 


05 


xnojg sqx 


iH (N »C -"i* CO ^ ■ 

T-t iH 




U'B;!^'BqU'BJ\[ 


iH (N Ol l> rH O • 

Cq O 00 CO "* (N ■ 

rH Tt< tH (N (M ■ 


O 
"5 


^?I0 ^JOA AN.9N 


Tt< 00 05 r-< r-l IC l> 

lO lO iM •* CO O 
Cq 00 00 lO -* 


IN 

05_ 

<N 






Diphtheria 
Scarlet fever . 
Measles 
Chickenpox 
Whooping cough 
Mumps 
Tuberculosis . 





150 INFECTIOUS AND COMMUNICABLE DISEASES 

Smallpox. — ^This disease is very rare among school children 
in cities where medical inspection is established, thanks to 
the wise laws that make vaccination compulsory for school 
children. It is unnecessary to devote any space to a defence 
of vaccination in order to convince a legally qualified physi- 
cian, but there are cases when stubborn parents can be 
induced to submit their children to vaccination without 
invoking the laws, by a tactful explanation on the part of 
the medical inspector. For this reason, it would be well for 
every inspector to acquaint himself with the contents of a 
circular entitled "A Message from the Medical Society of 
the State of Pennsylvania," a plain talk on vaccination. 

Symptoms. — ^The physical signs and symptoms of smallpox 
can be studied from any text-book on diagnosis or works 
devoted to infectious diseases. 

After an exposure to the contagion, and a period of incu- 
bation of ten days to two weeks, severe general symptoms 
manifest themselves, especially high temperature, backache, 
headache, delirium, and vomiting. A prodromal eruption 
appears, which is composed of erythematous or hemorrhagic 
spots occurring chiefly on the abdomen and inner sides of 
the thighs; this diminishes in a few days at the same time 
that the fever and general symptoms subside. The charac- 
teristic rash now appears, first on the scalp and face, then 
on the trunk, arms, and legs in the form of small, red nodules 
which increase in number and size and develop into vesicles 
with clear contents. The temperature again rises and the 
contents of the vesicles become cloudy and a small depres- 
sion or umbilication forms in the centre of the pustules. 
These remain discrete or run together if much of a rash 
exists. The rash is especially abundant and confluent on 
the face and hands. The mucous membranes of the eyes, 
mouth, and throat may be involved. In favorable cases 



PLATE VI 




Revaeeination. Revaceination. 

7th day. 7th day. 

Revaceination. 
Primary Vaccination. 7th day. Revaceination. 

8th day. 

From Polyclinic Collection of Drs. Schamberg and Wallis. Wax Models ■made from 
Life hij Dr. J. F. Wallis. 

Hare's Practice 



PLATE VII 




Evolution of Primary Vaccination. 

4th day. 6th day. 8th day. 

Crust 20th day. Scar 28th day. Spurious result. 

FroOT. Polyclinic Collection of Drs. Schamberg and Wallis. Wax Models made from 
Life by Dr. J. F. Wallis. 

Hare's Practice 



GENERAL CONSIDERATIONS 151 

the pustules begin to dry and form crusts in twelve to four- 
teen days, and separate in three or four weeks, leaving typical 
scars. The period of infection may last somewhat longer. 

Diagnosis.— The eruption in a fully developed case is 
typical of this disease only. It is to be suspected only in 
an unvaccinated person or one not vaccinated for a number 
of years. The diseases mistaken for smallpox are chicken- 
pox, measles, and syphilis. 

The medical inspector, especially in times of an epidemic 
of this disease, should be suspicious of every child having 
a doubtful vaccination, or on whom there appears a rash 
similar to smallpox with signs of acute illness. Chickenpox, 
varicella, must not be diagnosticated at such times unless, 
every evidence eliminates the possible mild case of smallpox. 

The diagnosis is sometimes extremely difficult in the 
early stages. The greatest importance should be attached 
to previous and recent successful vaccinations as seen by 
remaining scars. Pustular syphilis generally has a history 
of such infection and other specific manifestations on close 
examination. In chickenpox, the general symptoms are 
mild, the prodromal eruption and umbilication of vesicles 
are absent, and different stages of development of the erup- 
tion are present at the same time. Measles is occasionally 
mistaken for smallpox, but the eruption is papular, more 
confluent and does not advance to vesicular or pustular stage. 
There are marked respiratory symptoms and the general 
symptoms are milder. 

Vaccination. — Prophylaxis of smallpox is vaccination. 
The time to vaccinate is in the first year of life unless there 
are cases of smallpox in the city, when it should be performed 
at any age. All people who have come in contact with a 
case should be vaccinated irrespective of age or time that 
has intervened since the previous vaccination. The inti- 



152 INFECTIOUS AND COMMUNICABLE DISEASES 

macy of the contact is not to be considered. Vaccination 
has a five-day incubation period and smallpox twelve. 
Thus there is one week's gain on the disease by an early 
diagnosis, immediate quarantine, and vaccination of all 
contacts. Most contacts, if vaccination is successful, will 
not be infected, or if so, will result in a mild case. 

A vaccination is a typical sore on the skin produced by 
infection with the virus of vaccine, with a resultant white, 
cribriform scar. A sore arm due to infection with strep- 
tococci or other germs does not mean a vaccination. The 
only absolute test of the efficiency of a vaccination to pro- 
tect against smallpox is the failure of subsequent vaccina- 
tions when properly performed with potent virus. 

A successful vaccination can generally be told by the course 
of the appearance of papule, vesicle, pustule, and after-scar. 
Vaccination should be repeated once in seven years, and at 
other times when an epidemic of smallpox exists. This 
does not mean that the period of protection lasts but seven 
years. The time varies greatly and may extend over fifteen 
or even twenty years. The period of seven years simply 
keeps one within the lines of safety. 

The Operation of Vaccinatioji. — Choose a reliable virus, 
one that is fresh, and within the age limit set by the manu- 
facturer. Heat destroys vaccine virus, therefore it should 
be kept in a cool place. The best part of the body for the 
operation is on the left arm, over the deltoid muscle. The 
leg may be chosen in the case of a female, but this site is 
more susceptible to infection. The part should be cleansed 
with soap and water, dried, and washed with alcohol. Then 
scrape the upper layer of skin with a knife, needle, or scarifier 
over not more than an eighth of an inch of surface, until 
there is a slight oozing of serum, not blood. If ivory points 
are used, the virus is then rubbed into this area. If gly- 
cerinated tubes, the virus is blown into the area by means 



GENERAL CONSIDERATIONS 153 

of the tubes or bulb furnished with the virus. Never use 
the Hps to blow on the virus. The arm should remain bare 
a few minutes to allow the virus to dry, when a few turns 
of a gauze bandage may be placed around the vaccinated 
area. Discourage the use of shields. 

Legislation. — Most States and cities have some laws which 
either make vaccination mandatory among school children 
or give equal powers to the enforcement of such measures. 

The school law of Pennsylvania has a special provision 
for vaccination. 

"All principals or other persons in charge of schools as 
aforesaid are hereby required to refuse the admission of any 
child to the schools under their charge or supervision, except 
upon a certificate signed by a physician setting forth that 
such child has been successfully vaccinated, or that it has 
previously had smallpox." 

"Any physician, undertaker, principal, superintendent 
of a Sunday school, sexton, janitor, head of a family, or any 
other persons or persons named in this act who shall fail, 
neglect, or refuse to comply with or who shall violate any 
of the provision or requirements of this act, shall for every 
such offence, upon conviction thereof before any mayor, 
burgess, alderman, police magistrate, or justice of peace of 
the municipality in which said offence was committed, be 
liable to a fine or penalty thereof of not less than five dollars, 
nor more than one hundred dollars, which said fines or pen- 
alties shall be paid into the treasury of such municipality, 
and in default of payment thereof, such person or persons 
so convicted shall undergo an imprisonment in the jail 
of the proper county for a period not exceeding sixty days." 

The State of Massachusetts has a statute that has been 
a school law since 1855: 

"A child who has not been vaccinated shall not be admitted 
to a public school except upon presentation of a certificate 



154 INFECTIOUS AND COMMUNICABLE DISEASES 

granted for cause stated therein, signed by a regular prac- 
tising physician that he is not a fit subject for vaccination." 

One of the most salutary effects of medical inspection 
has been the enforcement of vaccination laws which pre- 
viously had been neglected. First inspections by inspectors 
show, especially outside of large cities, large numbers of 
pupils unvaccinated. In all of these cases the physicians 
have insisted upon the observance of the laws and vaccina- 
tion has become general. 

Every child that has received a successful vaccination, 
or on examination shows a recent mark or signs of having 
had smallpox, should be furnished with a certificate which 
should be kept on file at the school. 

Form of vaccination certificate used in Philadelphia. 

Department of Public Health and Charities. 

BOARD OF health. 

Physician's Certificate. 

Philadelphia. 191 

I hereby certify from personal examination that 

Age 

Residence 

is successfully vaccinated, or has had Smallpox. 

M.D. 

Residence. 

(OVER) 

Regulations of the Bureau of Health of 
Philadelphia. 

Authorized by an Act of Assembly 
Approved June 18, 1895, and April 20, 1905. 

Section 14. All principals, superintendents, or other per- 
sons in charge of schools, as aforesaid, are hereby required 
to refuse the admission of any child to the schools under 
their charge or supervision, except upon a certificate signed 



GENERAL CONSIDERATIONS 155 

by a registered physician setting forth that such child has been 
successfully vaccinated or that it has previously had smallpox. 

Such certificates of vaccination shall not have been issued 
sooner than five days after the performance of the operation, 
nor without personal inspection of the site of the operation 
by the physician issuing the certificate. 

Section 15. All principals or other persons in charge 
of schools, as aforesaid, are hereby required upon notice 
from the Bureau of Health to refuse the admission of any 
child of twelve years of age or over to the schools under 
their charge or supervision, except upon a certificate signed 
by a registered physician, setting forth that such child has 
been revaccinated within a period of four (4) years from 
the date of its application for readmission, and giving the 
results of the operation. 

The penalty for violation of the provisions of this section 
is punishable by a fine or by imprisonment. 

A medical inspector should never vaccinate a child in 
school without having obtained the written permission from 
a parent or caretaker. The following form is suited for 
obtaining such permission: 

Philadelphia, 191 

Bureau of Health: I hereby request the vaccination of 

residing at a pupil of 

.- _.-_!..._ School. 



Parent or Guardian. 



Vaccinated-.. ...191 

Inspected 191 

-n 1, f Successful 
Result ] 

Unsuccessrul 



Medical Inspector. 



156 INFECTIOUS AND COMMUNICABLE DISEASES 

Diphtheria. — Diphtheria is contracted by inhaling the 
expired breath of a case of the disease, or a diphtheria 
carrier (a clinically normal throat with the virulent germs 
in it), or from air contaminated by the germs from infected 
clothing or discharges from the ears, nose, and throat. 

Diagnosis. — Diagnosis is made by the characteristic exu- 
date forming a membrane on tonsils and pharynx or in 
nares or larynx. The other diseases resembling diphtheria 
are pharyngitis and follicular tonsillitis. Where a clinical 
diagnosis cannot be made, bacteriological cultures should 
be taken. 

All children with sore throat should be looked upon with 
suspicion, and diphtheria excluded only after laboratory 
examination shows an absence of the diphtheria bacilli. 
A trained eye can more often diagnosticate diphtheria from 
a follicular tonsillitis when exudate is present. A follicular 
tonsillitis shows dotted white glistening exudate covering 
tonsils only. These plugs of secretion can be removed from 
the holes with a probe without bleeding. Diphtheria is 
found as a dirty gray dull membrane which covers more or 
less space on tonsils and spreads to vault and uvula. At- 
tempts at removal with a probe are difficult, and cause 
bleeding. All sore throats with or without membrane should 
be cultured, and the child excluded from class-room until 
results of culture are known. Quarantine in diphtheria 
must be maintained so long as microscopic examination 
shows the presence of the diphtheria germs. 

Diphtheria Carriers. — Diphtheria carriers are people who 
show no signs or symptoms of the disease, but in whose 
throats are the germs of diphtheria. They are most dan- 
gerous individuals and can readily transmit the disease to 
others. When found on a school child, the child is excluded 
from school, the family notified to isolate the case, and, if 



PLATE VIII 





1. Follicular Tonsillitis. 2. Diphtheritic Throat. 



GENERAL CONSIDERATIONS 



157 



no physician is called, the medical inspector should take 
cultures. When a negative culture is obtained from nose 
and throat, the room occupied by the child is disinfected 
and the child may return to school. 

The use of the term "school" legally includes public, 
parochial, private, and Sunday schools. 

Fig. 31 






Culture for laboratory diagnosis of diphtheria. 



Cultures. — All health departments of large cities are 
equipped with a laboratory for examining cultures. These 
culture outfits, which should be part of the outfit of every 
school inspector,, consist of a package containing two test- 
tubes — one tube containing a sterile swab of cotton on an 
applicator — the other, the culture media. The physician 
rubs the swab of cotton over the diseased area and then rubs 
it on the surface of the culture medium without breaking 
the surface. The cotton plug is returned to the tube and 
with the required data of information the outfit is sent to 
the laboratory. As it takes twenty-four hours for the 



158 INFECTIOUS AND COMMUNICABLE DISEASES 

result of such examinations, the physician should make 
every effort to diagnosticate the case on clinical signs and 
symptoms. 

Antitoxin. — ^There should be no need to enter into any 
discussion as to the value of antitoxin as a preventive, 
and curative agent in diphtheria. It is the delay in its use 
that endangers the life of the patient. In the Philadelphia 
Hospital for contagious diseases no case has died that has 
received a dose of antitoxin in the first twenty-four hours 
of the disease. Before antitoxin was discovered the death 
rate from diphtheria was 30 to 50 per cent. Since the 
use of antitoxin the mortality is but 10 per cent. Many 
cities furnish antitoxin free, and upon request, medical 
inspectors to administer it. Since February, 1913, New 
York City no longer permits the administration of anti- 
toxin by the inspectors, although the serum is furnished 
free upon request. 

Scarlet Fever. — Scarlet fever is more often found by the 
school physician in the early stages when the child has a mild 
erythema and pharyngitis with accompanying early symp- 
toms of vomiting and fever or in the stage of desquamation. 
A child vomiting in the class-room should be looked upon 
with suspicion, carefully examined, and, if necessary, ex- 
cluded for a day or so. 

Scarlet fever is to be diagnosticated from pneumonia, 
pharyngitis, indigestion, measles, and diphtheria in early 
stages. It is the mild cases with few. symptoms that return 
after an absence of a few days from school, that infect many 
others and cause epidemics. 

Scarlet fever must be quarantined for a period of not less 
than thirty -five days from the date of reporting the case to 
the Bureau of Health by the attending physician or others. 
All cases must be examined by an inspector when the case 



GENERAL CONSIDERATIONS 159 

is declared terminated by the physician. Examination is 
especially made for peeling or desquamation, also discharges 
from nose and ears. Desquamation of soles of feet and palms 
of hands takes place later than other parts of the body. 

Fig. 32 




Well-marked desquamation upon the dorsum of hands and fingers of a case 
of scarlet fever. (Welch and Schamberg) . 

Measles.- — No other infectious disease is more frequently 
found in the schools by the physicians than measles. 
This is partly due to the ignorance of some parents in 
believing measles not serious, and that all children must 
get it, and partly to their mistaking the respiratory symp- 
toms as a mere "cold." A pupil with "watering eyes," 
lacrymation, sneezing, coryza, and cough should be looked 
upon with suspicion. By these symptoms a diagnosis can 



160 INFECTIOUS AND COMMUNICABLE DISEASES 

often be made previous to the rash appearing and the child 
can be excluded. This disease more than any other one of 
childhood, plays havoc in a school by its rapid dispersion. 
Koplik's spots may be seen, but are more often overlooked. 
The characteristic papular eruption beginning on the fore- 
head, neck, and wrists, together with respiratory symptoms, 
cannot be mistaken for any other disease. Diagnosis in 
the early stages must be made from scarlet fever and 
diphtheria. 

Quarantine for measles should be instituted as early as 
possible. This must be continued for fourteen days, and 
the child kept from school for one week more, a total of 
twenty-one days. The same period of exclusion should be 
enforced on those of the family exposed and who have not 
previously had measles. 

Rubella, German Measles. — Rubella, German measles, 
occasionally found at school, must be diagnosticated from 
scarlet fever. Rubella is much milder in its symptoms, the 
rash is papular instead of the erythema, and there is a 
swelling of the cervical glands. 

Varicella. — Varicella, chickenpox, next to measles, is one 
of the contagions most frequently met with at school. The 
child is seldom sick enough to remain home. The rash, 
varying in size, in all stages of papules, vesicles, pustules, 
and crusts, superficial in character, makes a clinical picture 
characteristic of this disease. Care must be exercised in 
diagnosis when smallpox is prevalent. 

Pertussis. — Pertussis, whooping cough. Teachers are apt 
to send to the medical inspector, with a diagnosis of whoop- 
ing cough, every child that coughs. The frequency of these 
mistakes should not make the physician any less alert 
in diagnosticating these cases. If the child has the typical 
"whoop," with vomiting, etc., the diagnosis is easy; but to 



PLATE IX 





8. Stra\^^berry Tongue. 



4. Koplik's Spots. 



PLATE X 



Fig. 1 



Fig. 2 





Fig. S 



Fig. 4 





The Pathognomonic Sign of Measles (Koplik's Spots; 



Fig. 1. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated 
rose-red spot, with the minute bluish- white centre, on the normally colored mucous membrane. 

Fig. 2. — Shows the partially diffuse eruption on the mucous membrane of the cheeks and Ups; patches 
of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. 

Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely 
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin 
is at this time generally fully developed. 



Fig. 4. — Aphthous stomatitis apt to be mistaken for measles spots. 
Minute yellow points are surrounded by a red area. Always discrete. 



Mucous membrane normal in hue. 



GENERAL CONSIDERATIONS 



161 



avoid unjustly excluding a case of bronchitis for whooping 
cough requires skill on the part of the inspector. The typical 
cough can be produced in a suspicious case by having the 
child run up and down the playground a few times. Cases 
of whooping cough are excluded from school for thirty days 

Fig. 33 




Mumps. 



from the date of reporting to the health department. The 
other children in the family, if unaffected, are not excluded. 
Mumps. — Mumps is a highly contagious disease, most 
prevalent in children. For the first ten months of 1912, 
1764 cases were reported to the health ofl&ce in Philadelphia. 
11 



162 INFECTIOUS AND COMMUNICABLE DISEASES 

The disease develops in two to three weeks after exposure. 
The early symptoms are fever with pain below the ear on 
one or both sides; a slight swelling below one ear may be 
noticed. In a day or two there is a decided enlargement 
of the neck and side of the cheek, which spreads to the 
other side of the face. The swelling persists for seven to 
ten days and gradually subsides. The typical swelling of 
the parotid gland is easily diagnosticated. Abscess from 
carious teeth can be diagnosticated by the location of the 
swelling, and the presence of decayed teeth. 

Quarantine for mumps should be twenty-one days from 
the date of reporting to the Bureau of Health. Children 
exposed to the disease must be excluded from school for 
three weeks following last exposure. 

Syphilis. — Syphilis in its hereditary form is more com- 
mon among children than is accredited to the disease. The 
eruption when present is rarely on the uncovered part of 
the body. The child may show the anemic, undeveloped 
appearance characteristic of some cases. Iritis may be the 
most prominent sign, and Hutchinson's teeth and frequent 
attacks of nasopharyngeal catarrh may be found. Glandular 
enlargement is often present. This disease is not uncommon 
among the subnormal and mentally defective children. 

Tuberculosis.— The relation of the school physician and 
cases of tuberculosis among school children is one that does 
not necessitate an extended study in a volume of this kind. 
The school medical officer is not permitted to undress a child 
to make a thorough physical examination, nor has he the 
means at his command for laboratory examinations. He 
can, however, label a child "suspicious tuberculosis," and 
refer the case to the family physician or a dispensary for a 
thorough examination and treatment. The school physician 
may recognize the "predisposed" pupils and advise open 



GENERAL CONSIDERATIONS 



163 



air or cold-room schools. He may interest the parents to a 
more healthful outdoor life ior the child and the nurse may 



Fig. 34 




Hutchinson's teeth. (Stowell.) 



investigate home conditions and remedy many defects that 
may benefit the child. Cases of tuberculous joint or bone 



164 INFECTIOUS AND COMMUNICABLE DISEASES 

disease are met with in various stages and should be referred 
for treatment to one of the orthopedic dispensaries. All 
cases of tuberculosis in children are excluded by law, in 
many States, from attendance at school. Some of these 
children can receive an education and at the same time im- 
prove their physical condition by attending open-air schools. 
The active tuberculous child, however, has no right to attend 
any school. The physicians should be acquainted with all 
the early signs and symptoms of tuberculosis and try to 
recognize the early cases and those predisposed to the 
disease. He has the opportunity of playing an important 
part in the campaign for the prevention of tuberculosis. 



PART IV. 
PHYSICAL DEFECTS. 



GENERAL CONSIDERATIONS. 

While the essential object of school inspection is the/ 
detection of contagious diseases among the pupils, of no 
less importance is the diagnosis and correction of physical 
defects. The medical inspector in his routine visits to the 
schools, has sent to him by principal, teachers, and nurse, 
pupils who have some signs or symptoms suspicious of a 
contagion, and those who have evident physical defects, 
which seem to hinder their physical and mental development. 
These cases are also detected by the physician in his class- 
room inspections and thorough individual examinations. 
The physical status of each pupil, at least once a year, is 
noted on record cards described under the chapter of 
" Records and Record Keeping." 

After the medical inspector has visited his schools and 
disposed of the cases that may be sent to him, he proceeds 
to the school where he intends making complete physical 
examinations. Here he examines ten or more pupils and 
records the results and recommendations. The inspection 
for evidence of successful vaccination is best done at the 
beginning of the school term for all pupils. Thereafter, all 
newly admitted pupils are examined on a certain day each 



166 



PHYSICAL DEFECTS 



week, agreed upon by the principals and the doctor. The 
physical examinations are preferably started in the highest 
grades and proceed to the lower. If the older pupils are 
promoted to other schools their examination has been 
accomplished, and the records of physical examinations 
may be transferred with the pupil. Any defect noted and 
not corrected may then be followed up by the physician 
in such school. 

The frequency of the various defects found in the schools 
of different cities is of interest as well as a guide for com- 
parison of results. 



City of Philadelphia, 1911. Summary of Work Performed by 
Medical Inspectors in Public Schools. 



Number of schools visited 

Number of visits to schools 

Number of major contagious diseases found in routine 

examinations 

Number of pupUs excluded 

Number of pupils instructed and referred to nurse 

Number of individual examinations 

Total number of vaccinations 



Average 



238 
18,306 

632 

4,755 

48,335 

59,159 

5,989 



Summary op Exclusions. 



Diphtheria 81 

Diphtheria contact ... 27 

Scarlet fever 59 

Scarlet fever contact ... 11 

Measles 117 

Varicella 215 

Pertussis 28 

Mumps 94 

Pediculosis 1,934 

Ringworm . . . . . 255 



Conjunctivitis 829 

Scabies 214 

Impetigo 427 

Miscellaneous 399 

Tonsillitis 42 

Measles contact .... 10 

No vaccination mark ... 2 

Trachoma 4 

Measles suspect . . . '. 2 

Favus 5 



GENERAL CONSIDERATIONS 



167 



Method of Inspecting Pupils. — ^The physician should have 
a routine method of conducting the physical examinations. 
Besides his other duties, he is supposed to make from ten 
to twenty physical examinations each day. These examina- 
tions, depending upon the ability of the inspector and the 
thoroughness of the inspection, take from ten to twenty 
minutes for each pupil. 



City of Chicago Physical Examinations of School Children. 

Summary for the Years 1909, 1910, and 1911. 

Per cent, of 

Totals totals ex- 

1909 1910 1911 (3 yr.) amined 

Number of pupUs examined . . 123,897 120,301 73,405 317,603 

Number having physical defects p3,199 53,868 31,230 148,297 46.6/ 

Per cent, found defective . . . 51 44.8 42.5 46.6 

Defects found — 

Teeth 44,483 43,922 27,676 116,081 36.5 

TonsUs— hypertrophy of , . . 27,556 24,286 15,097 66,939 21 . 1 

Eye— vision impaired . . . 21,824 18,941 11,524 52,289 16.4 

other defects of .... 32 439 905 1,376 0.4 

Glands— enlargement of . . .. 16,945 16,639 11,459 45,043 14.1 

Adenoids 4,088 4,702 3,465 12,255 3.8 

Nasal breathing impaired . . 6,524 5,032 ^,380 14,936 4.7 

Anemia 3,606 2,979 1,666 8,251 2.5 

Nutrition 2,983 2,399 1,576 6,958 2.2 

Skin diseases 2,593 1,955 1,451 5,999 1.9 

Ear— hearing impaired . . . 2,830 1,916 959 5,705 1.7 

discharging 13 208 363 584 0.2 

Goitre 50 335 630 1,015 0.3 

Palate defects 273 422 498 1,193 0.4 

Orthopedic defects .... 1,483 916 417 2,766 0.9 

Heart diseases 816 576 290 1,682 0.5 

Nervous diseases 486 564 277 1,327 0.4 

Lung diseases 425 173 153 751 0.2 

Rachitic type 23 . 124 204 351 0.1 

Mentally impaired .... 615 313 184 1,112 0.3 

Other defects 2 6 ... 8 . . . 

Totals 137,600 126,847 82,174 346,621 ... 



168 



PHYSICAL DEFECTS 



New York City.' Medical Inspection and Examination of School 
Childeen. Physical Examination of School Children. Non- 
contagious Physical Defects Found and Treated. 



Number of physical examinations made . 
Number found needing treatment 

Number found with other defects than of 

teeth only 

Number found with defects of teeth as 

only defect 

Percentage of those examined needing treat- 
ment 

Defects Found: 

Defective vision 

Defective hearing 

Defective nasal breathing 
Hypertrophied tonsils .... 
Tuberculous lymph nodes . • . 

Pulmonary disease 

Cardiac disease 

Chorea 

Orthopedic defect 

Malnutrition 

Defective teeth 

Defective palate 

Number reported treated^ .... 



1911 


1910 


230,243 


266,426 


166,368 


196,664 


75,857 


101,602 


90,511 


95,062 


72% 


74% 


24,514 


29,634 


1,491 


1,519 


27,316 


40,946 


34,639 


50,012 


418 


759 


483 


656 


1,661 


2,370 


861 


951 


1,190 


1,683 


5,845 


8,691 


135,843 


164,250 


85 


153 


65,150 


64,861 



1909 



231,081 
172,112 

102,150 

69,962 

74.48% 



30,408 

2,340 

43,393 

50,934 

810 

744 

1,503 

940 

1,461 

7,249 

131,747 

324 

84,968 



As the child enters the room, the inspector notes his 
gait and standing posture. In a low tone he asks the pupil's 
name, age, address, etc., and by the promptness of the 
reply or the pupil asking to have the question repeated he 
gets a preliminary idea of the condition of hearing and some- 
times mentality. He observes any abnormalities of struc- 
ture, differences between right and left sides of the body; 
facial expression, whether mouth-breather, etc. He notes 
color of the skin, presence of anemia, jaundice, desquamation, 
rash, and cleanliness by observing face and neck from front 
and sides. It is not unusual to find a ringworm back of 



1 These figures do not include children reported with defective teeth as 
the only defect, whose treatment consisted only of instruction in oral hygiene. 



GENERAL CONSIDERATIONS 169 

the ear or on the back of the neck. He observes the hands 
on both sides for rash, desquamation, and cleanhness, also 
condition of the nails. As these observations are made 
while the child faces a good light near a window, the same 
position is used to examine mouth and throat. When the 
child opens its mouth, the inspector notes the condition of 
the mucous membrane and teeth; the presence of an odor 
may indicate uncleanliness of mouth, carious teeth, or naso- 
pharyngeal catarrh. The tonsils are inspected to see whether 
they are hypertrophied or if an exudate is present; then the 
uvula, to see if it is elongated or if signs of nasopharyngeal 
catarrh exist. Mouth-breathing or signs of nasal obstruc- 
tion are noted. Ears are next observed for impacted cerumen 
or any discharge. Eyes are inspected for any of the inflam- 
matory diseases of the conjunctiva, cornea, or lacrymal 
apparatus and the presence of strabismus or ptosis of eyelids. 
The child is requested to stand erect with feet together and 
hands to the sides, while the physician notes any deformi- 
ties or orthopedic defects by viewing the child from all sides. 
Having obtained all possible data from a thorough inspec- 
tion, the physician then tests the hearing and vision. The 
defects found by the school examiner are referred for treat- 
ment to the family physician or dispensary. Care should 
be exercised in statements of defects and diseases, as a great 
number of errors in diagnoses sent to members of the medical 
profession lower their estimate of the proficiency of the 
corps. 

The eyes and ears are possibly the only parts of the body 
which receive an examination other than that of mere 
inspection. A few cities attempt to examine the chest and 
use stethoscopes, but information from a hurried examination 
through clothing is worthless. 

In testing for acuity of vision, the child is placed with his 



170 PHYSICAL DEFECTS 

back to the light and free from any reflection from the sur- 
face of the test card. Covering the eye not under examination, 
generally the left, the child is asked to recognize the letters 
beginning with the largest type. If the child reads correctly 
all the letters including those on the line marked 20 feet, 
and he is 20 feet away, the vision for that eye is recorded 
f or normal. If he recognizes no farther than the 40 foot 
line, then vision is recorded fg^, etc. The same method 
is adopted if meters are used for recording the acuity. If 
the child cannot see even the largest letter on the card, he 
is brought nearer until he can distinguish the top letter, when 
the acuity is noted by the distance of the child in feet or 
meters from the card used as a numerator and the designated 
type read as the denominator. The left eye is then tested 
in the same manner, after covering the right eye. 

A more complete discussion and criticism of testing vision 
and test cards will be found under the chapter on the eyes. 

Acuity of Hearing. — An accurate, scientific study of the 
acuity of hearing can be obtained by using one of the audi- 
ometers designed for such purposes. These instruments for 
school inspection are almost unknown outside of the psy- 
chological clinics and the dispensaries for diseases of the 
ear. The whispered voice or watch test is satisfactory, and 
preferred by most physicians. The child stationed about 
15 or 20 feet away and with his back toward the physician, 
is instructed to cover one ear completely. The physician 
whispers in a distinct, clear voice, words, numbers, or letters, 
which are to be repeated by the pupil. Each ear is tested 
separately, and it is sufficient to note hearing, right or left 
ear, defective or normal. 

The watch test consists in standing back of the pupil, 
and with one ear tightly closed he is requested to tell when 
he hears the tick of the watch held before the open ear. 



THE EYES 171 



THE EYES. 



Diseases and Their Prevalence.- — The examination of the 
eyes of school children should receive special attention from 
the medical examiner, as no other organ of the body has a 
greater influence on the child's welfare. The examination 
should include the eyes and their appendages, for inflam- 
matory and non-inflammatory diseases, and defects of 
vision. About 10 per cent, of the cases found are diseases 
of the eyes, chiefly, inflammatory, and the remaining 90 
per cent, are defects of vision. 

Any of the many diseases described in text-books on 

diseases of the eye may be found among school children, t 

but there is little need of the school examiner having an 
* . . . 

mtimate knowledge of the signs, symptoms, and diagnosis 

of all of these diseases. It is sufficient to be able to distin- 
guish the normal from the abnormal, and to recognize the 
common prevalent diseases and refer the cases to a competent 
ophthalmologist. 

Diseases may affect the eyeball, the eyelids, or the lacry- 
mal apparatus, and those defects which can be diagnosti- 
cated by inspection are within the realm of a school inspec- 
tor. Where defects exist in the hidden structures accessible 
only by the ophthalmoscope, as in the choroid, retina, and 
nerve head, they are likely to be overlooked. Several 
diseases of the eye show little or no outward signs of the 
disease, and may be recognized only by the careful examina- 
tion of a trained specialist. Inflammatory diseases of the 
eye recognized by redness, a watery discharge, and photo- 
phobia, or inability to stand light, should be cautiously 
labeled. The teacher's diagnosis of "conjunctivitis," 
"pink eye," "inflamed eye," etc., may be a most serious 
case of iritis or glaucoma. Sometimes the belittling of an 



172 PHYSICAL DEFECTS 

"only inflamed" eye is the cause of slowly healing corneal 
ulcers. 

Reports from various cities tell of finding acute conjunc- 
tivitis, chronic conjunctivitis, keratitis, choroiditis, cataract, 
pannus, etc., and as the physicians are more or less specialized 
on this subject, varied the list of subheadings. It is impos- 
sible to train each medical inspector to be a specialist in 
all branches of medicine. 

In cities or towns where no physicians are employed, 
the nurses or teachers who perform the work should be 
acquainted with the gross anatomy and appearances of a 
normal eye, but need not burden their memories with defini- 
tion, diagnosis, and pathology of the various diseases. They 
should also be intimately acquainted with the rules of hygiene 
for the eyes, should teach such rules on all possible occasions, 
and see that all dangerous contributing causes are removed 
from the school -room. The examination of the child should 
be thorough enough to recognize defects in the acuity of 
vision, inflammation of the eyes, swelling, edema, or puffiness 
of the lids, as well as other symptoms signifying disease. 
It is well to remember that these signs may mean more 
than a mere local affection, and may be a symptom of a 
more serious disease. 

An acute conjunctivitis with "watering" of the eyes, 
associated with catarrhal symptoms, may be prodromal of 
measles, and occasionally in the early stages of scarlet 
fever or chickenpox there is an injection of the conjunctiva. 
Redness of the eyes with subconjunctival hemorrhages may 
indicate the presence of whooping cough, and the diagnosis 
may be confirmed by hearing the typical cough. Scarlet 
fever and other acute exanthemas have associated fever and 
characteristic eruptions. 

Conjunctivitis must be diagnosticated from trachoma, a 



THE EYES 173 

contagious inflammatory disease of the lids. Trachoma is 
diagnosticated by a characteristic foHicular or trachoma 
body appearance most marked on the conjunctiva of the 
upper Hd. 

All forms of conjunctivitis with mucopurulent secretion 
is contagious to a greater or less degree, and requires 
exclusion from school. 

Most of the cases of trachoma found in the public schools 
have been diagnosticated as conjunctivitis, and the true con- 
dition has been later recognized by specialists. This is partly 
due to the school examiner confining his inspection to the 
lower lid, and finding no trachoma granules. INIany of the 
cases of trachoma show little outward signs of inflammation 
and can be detected only upon evertmg the upper lid. A 
peculiar drooping of one or both lids, a narrowing of the slit, 
and a pufiiness of the upper lid in an Italian or Russian 
child may lead one to suspect the presence of trachoma. 

The cornea should always be transparent, smooth, and 
glistening. Keratitis or corneal inflammation makes the 
membrane cloudy or hazy. Corneal ulcers often begin at 
th margin or limbus and show as an irregularity in the other- 
wise smooth surface. Ulcers when overlooked may cause 
serious damage to the eye and permanent impairment of 
vision. Hazy or clouded cornea may signify a serious disease 
of the eye. 

Unequal pupils or failure to react to light or accommoda- 
tion are abnormal signs and may signify some cranial 
trouble. If one pupil is dilated, before looking farther for 
the cause the examiner should ascertain if the child has 
been using drops. 

Puffiness of the eyelids or around the eyes may signify 
an organic disease of the kidneys or heart, or may be due 
to eye-strain or loss of sleep. Repeated attacks of inflamed 



174 PHYSICAL DEFECTS 

eyes, styes (hordeolum), crusts, and inflamed edges of lids 
generally denote the need of correcting lenses. It must be 
born in mind, however, that vermin, head-lice, or uncleanli- 
ness often cause crusts and inflamed edges of the lids, and 
can be verified by examining the scalp. 

If an eye becomes suddenly inflamed, the examiner 
should look for a particle of dust or other foreign body on 
the eye or conjunctiva of the lid before seeking some more 
serious cause. 

The treatment of a simple acute conjunctivitis or inflamed 
eye where there is no complication, or where a foreign body 
has been removed, consists in flushing the eye with a solu- 
tion of boric acid (a teaspoonful in a glass of warm distilled 
water). This can be done with an eye dropper or the child 
can use an eye bath or eye cup. These small glass cups 
are inexpensive and can be purchased from any druggist. 

Method of Examining Eyes. — The medical inspector should 
be most careful in his inspection of the eyes of children, as 
no other defect has a more important bearing on their 
education. Failure to recognize defective vision or some 
disease of the eye may mean failure to aid a subnormal or 
mentally defective pupil. 

It is unnecessary in a volume of this size to give the defini- 
tion, pathological anatomy, and symptoms of the various 
diseases of the eyes. Where a school physician is unac- 
quainted with the subject he can readily refer to one of 
the many good text-books on the subject. The following 
facts, however, are important and should be known by 
every school inspector. 

Diagnosis of diseases is made chiefly by inspection and 
defective vision by the use of test cards. 

Inspection. The eyeballs should not be so prominent as 
to protrude beyond the sockets (exophthalmos). There 



THE EYES 175 

should be no drooping of one or both eyelids (ptosis). 
The margins of the lids should show no crusts^ redness or 
swelling (blepharitis). The conjunctiva of the eye or lids 
should not be red, injection denotes conjunctivitis, and small 
papulopustular eruption on the edge of the lids constitute 
styes (hordeolum). Pupils in normal eyes are equal and 
the cornea and all media are clear and transparent. The 
surface of the cornea should be smooth and regular and the 
curvature in all directions should be the same. Breaks or 
irregularities of the surface of the cornea may be due to 
ulcers, and haziness or cloudiness due to keratitis. Growths 
on the conjunctiva may be due to pterygium, pinguecula, 
pemphigus, or tumor. Irregular shape of pupil, which in 
the normal eye is perfectly round, may signify a former 
inflammation of the iris. Iritis or inflammation of the iris 
is accompanied by a reddened conjunctiva. A normal lens 
should show no signs of opacity. 

The lacrymal apparatus comprises the lacrymal glands 
with their ducts situated at the upper and outer angle of 
the orbit and its drainage system is placed at the inner edge 
or canthus of the eye. The passageway for the tears is 
through the nasal duct emptying into the nostrils. The eyes 
are kept moist by the secretion of tears from the glands, 
and all surplus secretions are carried through this duct to 
the nose. When one gently pulls down the lower lid, there 
is visible at the conjunctival margin of the lid near the 
inner angle the opening to the canaliculi which leads to the 
sac. The tears or secretion drain into this system by suction, 
and except when in excess from crying the tears should not 
roll over the cheeks. There should be no swelling, purulent 
secretion, or other signs of inflammation of any of these 
parts. 

Both eyes should have their axes parallel and strabismus 



176 PHYSICAL DEFECTS ^ 

or squint is the condition present when the visual axes of 
the two eyes are not directed simultaneously on the same 
object. This defect may be sufficient to cause double 
vision. The eye directed toward the object is known as 
the "fixing eye," and the one deviating from the object 
the "squinting eye." 

Involuntary contractions of eyelids to reduce the amount 
of light entering the eye is known as "blepharospasm," 
and may be due to a foreign body on the cornea or conjunc- 
tiva, disease of cornea or conjunctivitis, ingrowing or mis- 
placed eyelashes, refractive errors, and occasionally disease 
of the nervous system. 

Involuntary lateral movements of the eyeballs (nystag- 
mus) may be caused by a disease of the central nervous 
system. This is sometimes seen in mental defectives. 

The existence of any of the diseases described above can 
be detected by a trained physician in a few moments' inspec- 
tion with the light from a window. The patient faces the 
light and the examiner has his back to the window. After 
a careful visual inspection, the lower lid is pulled down, 
using the index finger of the right hand, and the child 
requested to look up toward the ceiling, which procedure 
gives a good view of the conjunctiva of the lower lid. Any 
undue redness or follicular condition on the conjunctiva 
should be noted, likewise, the presence of purulent secretion 
from the lacrymal duct. 

To inspect the conjunctival surface of the upper lid, it 
should be everted. To do this the examiner stands in front 
of the child, takes hold of the margin of the lid and lashes 
with the thumb and index finger of the left hand, and with a 
toothpick, match stick or probe in the right hand held against 
the lid and about parallel to its margin pulls the lid with 
the left hand away from the ball and quickly rolls it over 



THE EYES 177 

the probe. The child is asked to look down toward the floor, 
and the probe is removed. This will be found a very simple 
procedure after a little practice. It is painless, harmless, and 
the only way to observe the condition of the conjunctiva 
of the upper lid. Trachoma can be readily seen if present. 
When the examination is finished, gently pull the lid down 
and request the patient to look up to the ceiling. 

Conjunctivitis. — Conjunctivitis is an inflammation of the 
mucous membrane lining the inner aspects of the lids and 
the anterior surface of the eyeball. This mucous membrane 
is continuous with the membrane lining the nose and mouth, 
and is sympathetically affected by diseases of these cavities, 
as in coryza. A conjunctivitis is distinguished from an 
inflammation of the deeper tissues by the bright red vessels 
of the conjunctiva being easily traced. In inflammation of 
the deeper tissues there is a bluish or violet red diffuse 
injection, and the individual vessels do not show distinctly. 
When making a diagnosis it should be remembered that 
combinations of these affections often exist. , 

It is unnecessary for the inspector to intimately acquaint 
himself with the varieties of conjunctivitis, their pathology 
and bacteriology. 

It is well to remember that the presence of a foreign 
body, often a mere speck of dust or cinder, may be responsible 
for an active inflammation. Unless one is accustomed to 
removing foreign bodies from the eye it is safer to resort to 
flushing the eye with a solution of boric acid. Grave damage 
has often been done by inexperienced people fishing and 
probing in the eye for foreign bodies. 

Where an inflammation is due to irritation from a mis- 
placed or ingrown eyelash, the offending lash can readily 
be pulled out with flat tw^eezers. 

Corneal ulcers may be associated with conjunctivitis 
12 



178 PHYSICAL DEFECTS 

especially if it has existed for some time. If overlooked these 
ulcers may lead to serious complications and permanent 
impairment of vision. 

All cases of conjunctivitis associated with a mucopurulent 
discharge should be considered contagious and excluded 
until under treatment and the discharge arrested. The 
inspector sho^uld not accept the statement of a child that 
it is receiving treatment, as it may mean the use of home 
remedies or treatment by a druggist. The child should be 
required to furnish a certificate from the attending physician. 

Where there are repeated attacks of conjunctivitis with- 
out an apparent cause, and even though the child shows 
full vision by test cards, the inspector should insist upon 
an examination under a mydriatic. These cases often prove 
to be highly hyperopic. 

The school physician should acquaint himself with the 
appearance of three inflammatory diseases of the conjunc- 
tiva which occur more or less frequently among school 
children: (1) phlyctenular conjunctivitis; (2) follicular 
conjunctivitis; (3) trachoma. 

Phlyctenular conjunctivitis is characterized by blebs or 
vesicles in conjunction with an inflammation of the bulbar 
conjunctiva. There is redness, irritation, inability to stand 
light, and a mucopurulent discharge. This form of disease 
is common among children who are poorly nourished and 
live under unsanitary conditions. Tonics and fresh air are 
needed as part of the treatment. 

Follicular conjunctivitis is of importance because of its 
resemblance to trachoma. As the term implies, it is accom- 
panied by the formation of follicles or nodules on the con- 
junctiva. These nodules are regular in size and appear in 
rows of small white nodules covered with the glistening 
conjunctiva. It is seen in both upper and lower lids. This 



THE EYES 



179 



disease responds readily to treatment, while trachoma is 
more chronic and resistent. 

Fig. 35 






a, trachoma; b, phlyctenular conjunctivitis; c, follicular conjunctivitis. 



Trachoma. — Trachoma is a contagious disease of the con- 
junctiva associated with a formation of follicles and enlarge- 



180 PHYSICAL DEFECTS 

ment of the papilla, giving a granulated mass sometimes char- 
acteristic in appearance. The condition is best recognized 
deep in the upper retrotarsal fold by everting the upper lid 
so far as possible. The condition often appeared to the 
author as though a layer of finely chopped raw beef had been 
spread upon the conjunctiva. 

Reports from most cities show the diagnosis of trachoma 
to be a difficult problem. Follicular conjunctivitis is most 
often mistaken for the disease. The inspector need not be 
discouraged at such mistakes, for even experts on the subject 
are often in doubt and refuse to make a positive diagnosis 
except after two or three weeks' treatment. If the case at 
such time does not clear up, it is supposed to be trachoma. 
Of course, a bacteriological examination of the trachoma 
bodies can be made, but few physicians have such laboratory 
facilities. One may read any number of good descriptions 
of trachoma and yet fail to recognize a case. Only the 
practical experience derived from personal observation of a 
number of cases in the various stages can be of true value 
to the diagnostician. Pulling down the lower lid and noting 
a few enlarged follicles is deceiving, because trachoma, as 
generally found in our public schools, the trachoma bodies 
are found well up under the upper lid and can be seen only 
by inverting the lid with a probe or toothpick. The disease 
may be in an acute stage, with some secretion, or it may be 
chronic, with cicatricial tissue. The cornea must be examined 
for any consequent damage to this tissue. All cases of trach- 
oma in an acute or subacute stage with any secretion must 
be excluded from school, but when there is merely evidence 
of the remains of the disease, as cicatrization, this is not 
necessary. 

New York City reported in 1909, 45,615 cases of trachoma, 
of which 1392 were excluded. The inspectors gave to 



THE EYES 



181 



these cases 310,465 treatments and instructions. They also 
found almost 50,000 cases of conjunctivitis, of which 1338 
were excluded. In 1911 there were reported 15,245 cases 



Fig. 36 




Inspection of an eye for trachoma. 



of trachoma, of which 136 were excluded; 25,941 cases of 
conjunctivitis, of which 1137 were excluded. 

Philadelphia, for the year 1910, reported 45 cases of 
trachoma among public school children, and 10 cases in the 



182 PHYSICAL DEFECTS 

parochial schools. Four cases were found in institutions 
and three in young children below school age. In the same 
year there were reported 558 cases of conjunctivitis. In 
1911, of 78 pupils who were sent to the city ophthalmologist, 
24 were cases of trachoma; in 1912, of 81 children suspected, 
21 were true cases. This may seem to an ordinary observer 
as a small number, and that possibly many cases were over- 
looked. The author knows, however, from personal observa- 
tion, that it accounts for the greater number of cases in the 
schools. When one stops to consider that trachoma, which 
is more prevalent in foreign countries, is brought to America 
by the immigrant, and that the Government holds a strict 
supervision and examination of all persons admitted to the 
United States, deporting every case with the slightest 
suspicions of the disease — one can readily understand why 
we should not find many cases even in our large seaport 
towns. The trachoma generally found here are cases which 
have become quiescent, and after the child has been in the 
United States for a time, there is an exacerbation, with 
return of symptoms. 

Squint or Strabismus. — The subject of strabismus or squint 
among school children is of sufficient importance to warrant 
a small volume on the subject. The physician should know 
that most of the cases of strabismus are due to ametropia 
and an early correction by properly adjusted glasses, steadily 
worn, may mean the straightening of the axes of the eyes. 
It is in the primary grades where cases of squint should be 
recognized and treatment urged. 

Diseases of the lacrymal glands and passages, the iris 
and ciliary body, lens and cornea need no absolute diagnosis 
from the school doctor further than recognition of the exist- 
ence of some disease of these parts and the recommendation 
of treatment. Diseases of choroid and retina can only be 



THE EYES 



183 



diagnosticated by using the ophthalmoscope under proper 
lighting, and belong within the sphere of the oculist. 



Fig. 37 




Fig. 38 




Cases of squint or strabismus. 



184 PHYSICAL DEFECTS 

Defective Vision. — No physical defect is of more impor- 
tance with regard to the development of the child and the 
progress of its education than defective vision. It is one 
of the most frequent defects noted in inspections of school 
children. The data on the results of vision tests is extremely 
variable, due to the abihty of the examiners and the lack 
of uniformity in the methods employed. The reports from 
various cities show the number of children with defective 
vision to be from 10 per cent, to 90 per cent, of those examined 
In a dozen different schools in Boston, examination of the 
pupils of the five upper grammar grades by the different 
inspectors gave the number of cases of defective vision vary- 
ing from 8 to 50 per cent. In the towns and cities of Massa- 
chusetts the variation for different schools was 5 to 35 
per cent. 

In New York City in 1909, 30,408, or 13 per cent, of the 
children examined, were found to have defective vision. 
In Chicago there were found 15.9 per cent, and in Phila- 
delphia 10 per cent. 

Great difference in percentages of defective vision are 
due to a variability of what constitutes "defective" and 
the methods of examination. If testing visual acuity by 
means of test cards gave an accurate and reliable result 
showing the exact condition of the eyes, any teacher or 
even an older pupil could satisfactorily perform the examina- 
tion. The author does not agree with many of the writers 
on this subject that the testing of vision can be performed 
by teachers and others, for reasons which will be explained 
later. 

Defective vision is found everywhere in great numbers, 
mainly because every city requires an examination by test 
cards whether authorized by law or by rule. A number 
of States including Connecticut, Vermont, Colorado, and 



THE EYES 185 

Massachusetts have statutes that compel the teachers 
to examine the eyes of the pupils. The Connecticut law 
reads : 

Section 1. The State Board of Education shall prepare 
or cause to be prepared suitable test cards and blanks to 
be used in testing the eyesight of the pupils in public schools, 
and shall furnish the same with all necessary instruction 
for their use, free of expense to every school in the State. 

Section 2. The superintendent, principal, or teacher in 
every school, some time during the fall term in each year, 
shall test the eyesight of all pupils under his charge, accord- 
ing to the instructions furnished as above provided, and 
shall notify in writing the parent or guardian of every pupir 
who shall be found to have any defect of vision or disease, 
and shall make written report of all such cases to the State 
Board of Education. 

The Vermont laws as well as those of Massachusetts are 
similar to the above, but include an examination of hearing. 
Several State Departments of Health conduct tests . for 
vision and hearing in the graded schools of incorporated 
villages of the State. This is so in New York, Pennsylvania, 
and Utah. 

In 552 cities in the United States vision and hearing tests 
are conducted by teachers, and in 258 cities similar examina- 
tions are made by physicians. 

Many cases of defective vision in children can be diagnos- 
ticated only when a mydriatic is used and by examinations 
made with instruments of precision, such as the retinoscope 
and the ophthalmoscope under proper lighting. These cases 
belong to the oculist, as the schools offer no such facilities. 
It is important to avail one's self of expert knowledge on dis- 
eases of the eyes, as defective vision has a most direct and 
important bearing on the mentally defective and subnormal 



186 PHYSICAL DEFECTS 

child. The consideration of the subject from such a stand- 
point will be taken up in the chapter on subnormal pupils. 

There have been many reports from various cities classi- 
fying the number of cases of hyperopia, myopia, and astig- 
matism diagnosticated by the school inspectors using test 
cards. Physicians and laymen speak frequently of the near- 
sighted pupil. These classifications and expressions are often 
erroneous, and, to say the least, misleading, because it is 
almost impossible for a physician to diagnosticate the kind 
of ametropia except when the child is under a mydriatic and 
the physician uses instruments of precision, such as retino- 
scope and ophthalmoscope. Statistics show that the near- 
sighted child is in the minority, averaging less than 20 per 
cent, of the defects diagnosticated. 

A knowledge of the physiology of the eye and the power 
of accommodation explains the reasons for the deception 
in diagnosis by the use of test cards alone. Many children 
who can readily read the required distance on a test card 
may prove under a mydriatic, which paralyzes the accom- 
modation, to be an extreme case of defective vision. Under 
skilled examinations, the hyperopes vary from 75 per cent, 
to 85 per cent, of the defects found. 

In Philadelphia, Dr. Wessels, the ophthalmologist, diag- 
nosticated in 3397 children refracted under a mydriatic, 70 
per cent, hyperopic, 12 per cent, myopic, 9 per cent, mixed 
astigmatism, and 9 per cent, amisometropia. 

Test Cards. — The author does not mean to infer that test 
cards are worthless, as they are the only instruments at 
our command for use in the school-room, but that they 
should not be used for a final diagnosis. The fact that a 
child can see the five-meter line at a distance of five meters, 
signifies two things, either that the child may have normal 
vision or may be hyperopic. If this child shows any symptoms 



THE EYES 187 

of asthenopia, especially repeated attacks of headaches, an 
examination under a mydriatic should be advised. If the 
child before a test card does not get five-fifths vision, it may 
mean defective vision, which may be hyperopia, myopia, 
astigmatism, or any of the combinations. The use of the 
clock dial may assist in diagnosticating astigmatism. 

The test cards enable the laymen and physicians to pick 
out the glaring cases of defective vision, but there is no better 
means of detecting such cases among school children than 
the observing and interested teacher, who can tell more 
by continuous contact and watching the actions of the chil- 
dren than one who stands a child for a few minutes near 
a test card. A child at this moment may have acute vision, 
but at the same time while at work in the class-room may 
show the effects of eye-strain. 

Test cards are of various designs. The one most frequently 
used is that designed by Snellen, consisting of letters or 
figures accurately measured in dimensions for normal 
vision at varying distances. Some children, including for- 
eigners who have not learned the alphabet, must be examined 
by using "illiterate" test cards. 

The illiterate card most frequently used for testing the 
acuity of vision, consists of the letter E with the open spaces 
and arms pointing in various directions. The dimensions 
of the figures correspond with the sizes of the letters on a 
Snellen test card. 

The author has devised two test cards which have been 
successfully used for the very young, the illiterate, and the 
foreign child, who have not learned the English letters or 
numbers. One of these cards consists of pictures and sil- 
houettes of well known objects, and the other of hands with 
a varying number of fingers extended in various directions. 
In both cards the figures are scientifically measured in size, 



Fig. 39 




Author's test card for young children and illiterates. 



THE EYES 



189 



^ii.-#f i 




and conform to the scale adopted by Snellen. The card of 
pictures is especially valuable for children in the lower 
grades. The hands are 
particularly adapted for > 

foreign children who do 
not know the English let- 
ters or numbers and cannot 
tell the English word for a 
picture or object. With 
this card the child imitates 
with his hands what he 
observes on the card. These 
pictures of hands also take 
the place of the astigmatic 
chart, as in some cases of 
astigmatism, the number 
of fingers in a certain 
direction are frequently 
mistaken. 

Use of Test Cards.—The 
test cards should be placed 
where they have proper il- 
lumination. Daylight from 
a nearby window or sky- 
light may be used, but arti- 
ficial light properly reflected 
on the cards is preferable. 
Artificial light should be 
shielded from the eyes of 
the child by use of a shade 
or reflector, and the angle 

of reflection should be such as to avoid a glare on the surface 
of the cardboard. The height of the card should be such 




■% #■ 



Author's test card for illiterates 
and foreigners with no knowledge of 
English. 



190 PHYSICAL DEFECTS 

that the centre is on a line with the head of the child under 
examination. 

It is better not to expose to view more than one card at a 
time, as it confuses the patient. If several different types 
of cards are used they can be frequently changed, thus pre- 
venting the memorizing of letters or figures. This is impor- 
tant when the examinations must be made in the class-room, 
as many of the pupils awaiting examination have an oppor- 
tunity to study a card and memorize the letters. Another 
way of preventing this, is to require the child to read the 
letters from right to left. 

The child should be seated at a distance of 16 to 20 feet 
from the card, and each eye should be tested separately 
by covering the other with a piece of card -board. The child 
reads the letters aloud, beginning with the top line, which 
is in largest type. In recording the results of the test, the 
distance between the card and the child becomes the 
numerator of the fraction measuring the visual acuity and 
the smallest type correctly read according to the distance 
which it should normally have been seen becomes the denom- 
inator. These distances are marked after each line on the 
test card. If a child seated 20 feet from a card correctly 
reads the letters on the line marked 30 feet, and can read 
no farther, the visual acuity for the eye under examination 
is f-g-. The right eye is generally tested first. 

If some of the letters on a line are misquoted, the sign 
( — ) is placed after the fraction (M — ), meaning less than 
f f vision. 

It is a safe rule never to examine a child who is not under 
a mydriatic in the presence of its parents. If the child 
reads the small type, which is often the case in hyperopes, 
the physician will have great difficulty in convincing the 
parents that the child has defective vision. 



THE EYES 191 

The test with the astigmatic chart or clock dial is made 
in the same way as with other charts, except that this time 
the child is requested to tell which lines look the blackest 
and clearest. If all lines look alike one may infer that no 
astigmatism exists, but where a particular axis is mentioned 
it suggests error of refraction in the opposite axis. 

The test cards are valuable in some cases as a subjective 
test, but they make it possible to recognize only the glaring 
cases of defective vision or those cases in which there is 
not sufficient accommodation to overcome the defect in 
visual acuity. The test card does not permit of an accurate 
classification between hyperopes (far-sighted), myopes 
(near-sighted) and astigmatism. It is sufficient for the 
examiner to recognize that a defect exists and leave the 
diagnosis of variety to the experienced physician or oculist. 

Abuse of Test Cards. — The dangers of relying upon test 
cards for diagnosis is shown in the following incident: 

Recently, a principal of a public school published the 
results of an examination of about five hundred children, 
using the ABC letter test card and the illiterate E card, 
and compared the results. His method consisted of placing 
the child 16 feet from the card; if he saw correctly the letters 
of the 16 feet line, he was asked to step back 2 feet, and if 
he still read the letters correctly, he was designated as far- 
sighted. If he could not see distinctly every letter at 16 
feet, he was advanced 2 feet at a time until he accomplished 
the reading, and these cases were all labeled as myopic 
or near-sighted. His results recorded were as follows: 
With ABC card: Near-sighted, 65.8 per cent.; far-sighted, 
15.5 per cent. With the illiterate E card he found: Near- 
sighted, 8.1 per cent.; far-sighted, 82.2 per cent. Having 
obtained these directly opposite results, he very ingeni- 
ously formulated a theory to prove the illiterate E test 



192 PHYSICAL DEFECTS 

card built wrong. It happens, however, that the results he 
obtained with the illiterate card are nearer to being correct. 
Myopia in children is rare in comparison to hypermetropia, 
even if one does hear more about "the near-sighted child." 
The principal comments as follows: "I frequently found 
it necessary in all grades, especially in the primary grades, 
to allow the pupils to rest their eyes. , . Many eyes 
after reading a half dozen letters were filled with tears. . . 
It was not an uncommon thing for a pupil to have to move 
up to 12 feet in order to make out the direction of the E; 
but having once clearly seen it he could recognize the other 
directions with apparent ease at twice the distance." There 
is no desire to ridicule the work of this gentleman, but 
rather congratulate him on his honesty in publishing such 
a full and concise report after obtaining such extremely 
opposite results. His comments spell most plainly accom- 
modation. This principal is not the only one who has made 
the error of trying to tabulate the near- and far-sighted by 
means of the test cards. The author recently read the report 
of a physician who examined one thousand school children 
and used the following method: The pupil was placed five 
meters from a test card, and a convex spherical lens of a half 
diopter was placed in front of the eye; if the child said he 
saw better with this lens than with the naked eye he was 
registered as hypermetropic. If he saw better with a 
concave spherical lens of a half diopter he was considered 
near-sighted, and all others were normal. These statistics 
are worthless, as a child may easily overcome even a much 
stronger lens and see distinctly. 

Symptoms of Defective Vision. — ^There are two available 
methods for the school examiner in recognizing defective 
vision. (1) Use of test cards; (2) signs and symptoms of 
eye-strain. The author considers the latter the more reliable 



THE EYES 193 

method for an examiner not trained in the use of instru- 
ments of precision. 

These symptoms may be briefly described as impaired 
visual acuity, or the power to view objects distinctly at a 
distance, with complaint on the part of the child; redness 
or inflammation of the conjunctiva of the lids or eyeballs; 
repeated existence of styes; squinting of eyes and wrinkling 
of forehead; headaches on forehead, temples or base of head; 
nausea, especially when riding in cars; twitching of muscles 
of forehead or face resembling chorea; holding books nearer 
or farther from eyes than normal; presence of squint or 
cross-eyes; various nervous symptoms, even resembling 
epilepsy in some cases. One or more of these symptoms 
may be present or obtained from a history of the case. 
Occasionally no symptom may be complained of, but the child 
may lack the power of concentration or be deficient in cer- 
tain branches of study, such as reading or writing. When- 
ever any signs or symptoms of eye-strain are present, even 
though the child shows normal vision with test cards, the 
inspector should insist on an examination under a mydriatic 
(eye drops) by a competent physician or oculist. 

The Need of a Mydriatic. — There are two kinds of errors 
of refraction: (1) Manifest; (2) latent. The eyes have a 
power of accommodation, or overcoming errors, most 
marked among children. This is accomplished by changing 
the curvature of the cornea and possibly the lens, thus mak- 
ing the rays of light come to a focus on a short or long eye. 
The errors which persist in spite of this power of accommo- 
dation are called "manifest," while those which are over- 
come by it are called "latent." A mydriatic is a drug 
which when instilled into the eye prevents the power of 
accommodation and thus all the error becomes manifest. 
It is then possible to diagnosticate the true condition of the 
13 



194 PHYSICAL DEFECTS 

eyes and those which before gave full vision may now show 
half or even less of normal vision. 

The belief that the use of drops for such purpose is harm- 
ful is erroneous, but because of this belief the physician 
should always explain to a mother, who entertains such 
fears, the reason for their use. 

The question is frequently asked, "How old should a child 
be to admit of an examination of the eyes?" Any age 
after four or five years if the child shows marked symptoms 
of defective vision. 

Strabismus or squint is generally due to defective vision, 
and the results, especially to straightening the eyes, are more 
marked if the child is examined while young and necessary 
correcting glasses prescribed. If the squinting eye is long 
out of use, it may become a blind eye insofar as vision is 
concerned. 

■ Children who have been wearing glasses should be 
watched, and if they come to school without them, should 
be sent home for them. If the child persists in not wearing 
the glasses, possibly the glasses are not suited, or the frames 
are so ill-fitting as to give discomfort. Again, it seems crimi- 
nal to allow a child to sit in the class-room wearing a pair 
of glasses so out of adjustment that one lens is on the fore- 
head and the other upon the cheek. An example of such a 
case is shown in Fig. 41. 

When a physician writes a prescription for glasses, and 
the lenses are supposed to contain cylinders at a certain 
axis, to correct astigmatism, what results can be expected 
from the glasses if the patient wears the lenses at any axis? 
The patient has poor results and the physician receives the 
blame. Again, the proper fitting of the frames is as necessary 
as the proper lenses. Unless otherwise ordered for a certain 
effect, lenses should be so adjusted that the centre of the 



THE EYES 195 

lens is at the centre of the pupil. -A little attention by 
teachers to children wearing glasses would result in giving 
considerable comfort. Frequently a patient returns after 
a year or so and asks whether they need to change their 
glasses, because they cannot see as clearly as they did at 
first, and on adjusting the lenses the fault is easily remedied. 

Fig. 41 




Glasses need adjusting, a condition to receive attention from teacher. 

Many parents pay little attention to their children who 
have squint, because they believe it to be a congenital 
condition for which little can be done. It may be well to 
impress on such parents that a congenital squint is rare. 
It ofttimes happens, however, that a child inherits defective 
vision, and through this defect the squint is manifested. 
When a squint is congenital, there is frequently an accom- 
panying asymmetry of the orbits and possibly of the skull. 
It is stated by some that the asymmetry of the orbit 



196 PHYSICAL DEFECTS 

admits of the eye turning to adjust itself to the shape of 
the orbit. 

Teachers should aid the physicians in overcoming the 
opinion that "children should not wear glasses because in 
that event they must wear them forever." 

Hygiene of the Eyes. — School hygiene with an object of 
conservation of the eyes of the pupils should be constantly 
taught and practised. The child should learn the dangers, 
and the causes and effects of eye-strain. The class-room 
admits of various sources of dangerous glare — such as win- 
dows, text- and copy-books, maps, walls, and blackboards, 
and the child should learn how to avoid glare both in and 
out of school. To avoid glare from a blackboard, it may 
be tilted at an angle, just enough to reflect to the ceiling 
the direct rays from the sun, bright sky, or artificial 
light. 

Teachers should regulate the size of writings and drawings 
on the blackboards and each stroke should exceed the one 
minute angle as seen from the farthest desk. It may be 
well to have a sample size of letter and stroke tacked on 
each blackboard. Teaching script writing by means of a 
blackboard is detrimental to the vision of the children. A 
child 40 feet away should have strokes a quarter of an inch 
wide and letters 6 inches high for normal vision. 

Copy-books and text-books should not have glazed paper, 
letters should be uniformly black, and of a size to be easily 
read at the ordinary reading distance. 

Standards should be adopted for the construction of text- 
books. The size and kind of type, spacing, width of margins, 
kind of illustrations, half tones or line drawings, the kind 
and finish of the paper, are all of extreme importance in the 
conservation of the eyesight. 



X 

< 




THE EARS 197 

THE EARS. 

Method of Inspection. — The school medical inspector, not 
having the equipment nor the proper reflected light needed 
for a thorough examination of the organs of hearing, may 
confine his examination to the recognition of defective hear- 
ing, and presence of discharges from the ears. The cause 
and technical diagnosis can be left to the family physician 
or the specialist. 

An inspection should be made in a good light before a 
window. The following conditions are looked for, the pres- 
ence of any unusual redness or swelling of the external ear 
or the surrounding tissue; any purulent discharge from the 
meatus; or wax and other foreign bodies closing the canal. 
After observation for any of the above diseases, each ear 
is tested separately for acuity of hearing. 

Method of Testing Hearing. — The hearing may be scien- 
tifically tested with an "audiometer," but this instrument 
has no distinct advantage over the watch or whispered voice. 
For school examinations the watch or whispered voice is 
usually employed, while the scientific instruments are used 
in clinics and laboratories. 

Watch Test. — This test is conducted as follows: the 
examiner stands in front of the child and requests him to 
close the left ear tightly with his left hand, and also to close 
his eyes. A watch is then held about 2 feet from and on a 
line with the right ear. The child is asked if he hears the 
tick of the watch, and if he answers in the negative the watch 
is brought slowly closer to the ear until the child claims he 
hears it. Normally, a watch tick should be heard at 1^ to 2 
feet. Results are then recorded — "Right ear, normal" 
or "Watch at 6 inches," etc. If the watch cannot be heard 
close to the ear, it should be placed against the mastoid 



198 



PHYSICAL DEFECTS 



bone behind the ear. If the tick is heard there and not 
in front, it signifies trouble with the conducting apparatus. 



Fig. 42 




Testing hearing with an audiometer 
Fig. 43 




Watch test for hearing. 



X 

w 




03 



CO 

z 

cC 


s- 

CO 
(D 
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THE EARS 199 

The left ear is tested in a similar manner, with the right 
ear closed. The examiner should be sure that the watch 
is in running order before recording results. The closing 
of the eyes is to prevent guessing, which can be detected 
by occasionally removing the watch and see if the child 
still claims to hear the tick. If under these conditions 
an affirmative answer is given, it is best to resort to the 
whispered voice test. 

Often suspicious cases of defective hearing can be detected 
as the child enters the room for examination. One simple 
method, but a good preliminary test, while the child is 
about 10 feet distant, is to ask in a low tone, "What is 
your name?" "How old are you?" or similar questions. 
Where defective hearing exists, and the child has been 
watching, he either notes the movements of the lips, or 
hears some sounds imperfectly, and the natural answer is, 
"What?" "Sir," etc. Suspicious cases should always be 
confirmed by further examination. 

Whispered Voice Text. — ^The child is placed in a corner of 
the room away from an open door or window, with his back 
toward the examiner to prevent his watching the movements 
of the lips. It is surprising how often a partly deaf child 
train's itself to interpret what one is saying by watching 
the lip movements. The child is instructed to repeat every 
word he hears, and is then requested to close the left ear, 
tightly with the left hand. The examiner, 20 feet distant, 
in a clear, distinct, low tone, pronounces words for the child 
to repeat. If properly interpreted, the ear is recorded 
"normal." If not heard, the examiner walks toward the 
child speaking as before until he comes near enough to be 
distinctly heard. The hearing for the ear under examina- 
tion is recorded, "whispered voice, 5 feet," or whatever 
the distance may be. The left ear is similarly tested. The 



200 PHYSICAL DEFECTS 

whispered voice is the most rehable and practical test for 
school children. 

Diseases of the Ear. — Impacted cerumen or wax is recog- 
nized in most cases by a causal inspection. This is often 
a sign of more serious trouble with the ear and should not 
be passed by as unimportant. These cases should always be 
referred to a physician or dispensary. 

Earache, when complained of by a child, should not be 
slighted, and as a precaution in home treatment, parents 
should be discouraged from pouring various hot fluids into 
an ear without consulting a physician. It is also advisable 
to warn parents and teachers of the dangers attending 
slapping the ears of children. 

A purulent or mucopurulent discharge from an ear should 
always be looked upon with suspicion, especially if a child 
has recently been absent for a week or so. Close questioning 
may reveal a recent case of scarlet fever, diphtheria, or other 
infectious disease. It is well when possible to make cultures 
of such discharges to enable a laboratory diagnosis. 

Even should a discharge from an ear prove to be benign, 
treatment should be insisted upon, as the odor is obnoxious 
to the classmates and the dangers to the child are numerous. 

Defects of hearing and diseases of the ear should require 
a careful inspection of the nose and throat for causative 
factors, as there is an intimate relation between these 
cavities. 

NOSE AND THROAT. 

The nose and throat are important cavities, requiring 
careful inspection by the school medical examiner. They may 
show the first signs and symptoms of an acute infectious 
disease or they may contain defects which greatly hinder the 
development of a child. These cavities play an important 




CD 

w 



NOSE AND THROAT 201 

role in breathing and in the faculty of speech. There is 
not available at the schools proper lighting or instruments 
for an exhaustive study of these cavities, and because of 
the hidden location of certain defects, it is impossible to see 
and accurately diagnosticate them without the needed equip- 
ment; nevertheless, careful inspection may aid in detecting 
some of the common defects and diseases. This is generally 
so with adenoids, enlarged or diseased turbinates, deflected 
septum, and growths. The teacher, nurse, and physician 
may note occlusion of one or both nostrils and mouth 
breathing, and infer that the child has adenoids. It is better 
to record "nasal obstruction" and leave the diagnosis of 
causative factor, whether adenoids, nasal catarrh, deflected 
septum, or lack of toilette of the nostrils to the attending 
physician or specialist. Several years ago the author sent 
fifty pupils who were diagnosticated by teachers and nurses 
as cases of adenoids, to a nose and throat specialist for reports 
on diagnosis. Only nine were found to have adenoids, 
while over one-half- had nasal obstruction and mouth 
breathing from a lack of cleanliness of the nostrils. 

A mucopurulent discharge from the nostrils accompanied 
by watering of the eyes may indicate measles. If a child 
has been absent for several days and returns with a nasal 
discharge, eliminate diphtheria and scarlet fever. Coryza, 
bronchitis, and hay fever have nasal discharge as a promi- 
nent symptom. If a child has a chronic, fetid discharge 
an atrophic rhinitis may exist, possibly accompanied by 
a growth. 

Foreign bodies, pencils, rubbers, and various other small 
articles are occasionally pushed into the nostrils. These 
can frequently be extracted with small tweezers. In the 
absence of tweezers, a hair-pin, with its ends bent to make a 
broader grasping surface, may answer the purpose. 



202 PHYSICAL DEFECTS 

Nosebleed is frequent in children, due to injury, catarrhal 
conditions, plethora, and more rarely cardiac or pulmonary 
affections. It may be controlled by applying ice to the 
base of the nose or nape of the neck, with the child in the 
recumbent position. A weak solution of tannic acid on a 
pledget of gauze inserted into the nostrils or an application 
of adrenalin solution may be reguired. 

Technique of Examination. — To examine the mouth, teeth, 
palate, tonsils, and pharynx, the child should be requested 
to open the mouth, but not to stick out the tongue. Then 
the examiner can observe the condition of teeth, tongue, 
and mucous membrane of that cavity. Ulcers or an inflam- 
mation (stomatitis) of the mucous membrane may be present. 
Foul breath may indicate carious teeth or want of cleanliness 
of the mouth, and a coated tongue may reflect gastro- 
intestinal derangement. The child should then be requested 
to protrude the tongue and say "Ah" (as in father). With 
a wooden tongue depressor on the tongue not too far back, 
the examiner can obtain a good view of the tonsils, uvula, 
and pharynx. 

The shape and condition of the vault of the mouth, size 
of uvula, presence of cleft palate, size and condition of ton- 
sils and pharynx, and the presence of any foreign growths, 
like adenoids in upper part of pharynx, all should be noted. 
Also any unusual redness of the tonsils or uvula, and pres- 
ence of any exudate, membrane, or follicular plugs should 
be carefully looked for, keeping in mind the possibility 
of scarlet fever and diphtheria. 

A suppurative tonsillitis or quinsy may push a red, 
swollen tonsil forward. Plugs of exudate in the follicles of 
the tonsils suggest a follicular tonsillitis. Deep ulcers upon 
the tonsils with surrounding tissue normal is suggestive of 
syphilis. All membranes, exudate on tonsils, pharynx, 



> 
>< 

< 




NOSE AND THROAT 203 

or adjoining tissues, should be cultured for diphtheria 
germs. 

The Voice. — The voice may often give valuable diagnostic 
signs. Whispered low sounds or harsh coarse voice may 
indicate an acute laryngitis, tonsillitis, or diphtheria. If 
subacute or chronic, it may be due to post-diphtheritic 
paralysis or habit tones. Mouth speech with absence of 
nasal sounds accompanied by mouth breathing indicates 
an obstruction in the nasopharynx or nostrils. 

Enlarged Tonsils. — Excepting adenoids, no other defect is 
more discussed in the examination of school children than 
enlarged or hypertrophied tonsils. Various cities report 
from 5 per cent, to 85 per cent, of the school population as 
suffering from this defect. This wide variation is due to the 
lack of a uniform standard of what constitutes an enlarged 
tonsil. Enlarged tonsils should mean only those defects in 
which the tonsils are large enough to give signs and symp- 
toms of obstruction to the upper air passages. One must 
consider the relative size of the throat in comparison to the 
size of the tonsils. A ragged, diseased tonsil though com- 
paratively small is more dangerous to the health of a child 
than an enlarged smooth tonsil giving no symptoms. The 
promiscuous removal of such tonsils, which seem a trifle 
larger than what we think they should be, is not to be encour- 
aged. "Hypertrophied tonsils" should only be recorded 
on the physical record card of a child, when such a diagnosis 
has been made by a physician or specialist in diseases of the 
nose and throat. 

Adenoids. — In some cities a medical inspector who has not 
diagnosticated a great number of cases of adenoids among 
his pupils is considered negligent in his duties, while in 
reality he is conscientious and worthy of commendation. 
Mouth breathing is not always evidence of the presence of 



204 



PHYSICAL DEFECTS 



adenoids, and a mere glance in the throat rarely shows these 
growths. The specialist never makes a diagnosis of this 
defect until he has passed a small mirror to the back of the 
throat and sees the growths reflected there, or has passed 
a finger back in the pharyngeal cavity and felt the irregular 

Fig. 44 




Antero-posterior section of the head, showing location of adenoids and 
difficulty of diagnosticating by simple inspection. 



masses. Therefore, although it is well to be suspicious of 
adenoids, the case should not be labeled as such until the 
growths are seen or felt. 

When adenoids and hypertrophied tonsils are present 
in a child, they may not only give acute and alarming 
symptoms, but may have a permanent effect on the 
child's health. Some of the effects produced are: 



NOSE AND THROAT 



205 



1. Danger of obstruction to breathing and improper 
aeration of the lungs, which may influence the health and 
mental development of the child. 

2. Changes in expression and contour of the face. 

3. Defective speech. 

4. Dangers of ear complications, inflammation, otorrhea, 
and defective hearing. 

Fig. 45 




Usual expression of a boy with adenoids. 



5. Increased liability to infectious diseases, especially diph- 
theria and scarlet fever. 

6. Frequent attacks of colds and nasal catarrh. 
Hypertrophied tonsils and adenoids have a tendency 

to become smaller during early adolescence and sometimes 
disappear in adult life. This, however, is no argument for 



206 PHYSICAL DEFECTS 

non-treatment of these defects as the above cited dangers 
are always present. In some cases the so-called disappear- 
ance of adenoids or enlarged tonsils as the child grows 
older is only a relative diminution in size. Here the growth 
remains stationary while the cavity of the pharynx and 
throat enlarges with the development of the child. 

Speech. — Normal speech is a clear, distinct, and audible 
pronunciation of sounds, letters, and words. It is dependent 
upon the normal condition of the nerve centres, larynx, 
pharynx, nostrils, vault of the mouth, tongue, teeth, and 
lips. The sense of hearing influences the sense of speech. 
Abnormality of any of these organs may be expected to 
cause defects of speech. 

To test speech, the child should be required to pronounce 
certain letters, and words containing combinations of these 
letters. The letters most frequently mispronounced are: 
b, m, n, f, p, V, w, o and u; also the dentilinguals d, t, th, 1, 
n, r and s. 

The defects of speech found among school children 
include : 

1. Aphasias. 

2. Tremulous, interrupted speech. 

3. Hesitating speech. 

4. Inability to pronounce certain letters. 

5. Stuttering. 

One or more of these defects are generally found among 
mentally defective children. 

Malformations of the oral cavity are chiefly those due to 
irregular teeth or shallow and small arches forming the 
palates. In the lower grades there is occasionally found a 
case of cleft palate or cleft lips. Any of these malformations 
may seriously interfere with speech. 



THE TEETH 



207 



THE TEETH. 

There can be no doubt as to the value of sound, normal 
teeth to the health and comfort of a child. The teeth reflect 
the general health as well as an attempt at healthy living. 
Foul, unclean, and decayed teeth reflect a carelessness, 
want of cleanliness, and a disregard of the rules for personal 
hygiene. The school inspector can readily recognize decay 
in teeth, if on the anterior surface or grinding edges of the 



Fig. 46 



Incisors or Canine „ , ^ . j. 

Cutting Teeth TocrtJi Molars or Grinding 




LOWER \ I \ 
TEETH 



Incisors v^»iMii^ 

Side view of upper and lower temporary teeth of the left side. These begin 
to appear at six months and are complete at two and one-half years. 

front teeth, but the primary trouble, which is the more 
important, is more often hidden along the alveolar borders, 
between teeth or on the back molars. Again, the age of 
school children includes the periods from six to ten years, 
which is the transitional period between the going of the 
temporary teeth and the coming of the permanent ones. 
If the school children of a city were carefully examined by 
dentists, 95 per cent, would be found with decayed teeth. 
For the above reasons, teachers, nurses, and medical 



208 



PHYSICAL DEFECTS 



inspectors should devote time to teaching the children the 
hygiene and care of the teeth, the use of a tooth-brush, 
tooth-powder, and oral cleanliness. Examination of the 
teeth and necessary treatment should be left to dentists. 
Where a city cannot afford to have a paid corps and a 
dental clinic, volunteers can undoubtedly be obtained. 

Fig. 47 



Blood Vessels and Nerves destroyed 




Dental caries. 



Dental Clinics. — ^While in a number of cities some dental 
work is performed among the school children, but four 
cities have dental school clinics. 

In Philadelphia a dental dispensary was organized October 
5, 1910, with two hundred and ten volunteer dentists. The 



THE TEETH 
Fig. 48 



209 




Dental nerves. 



Fig. 49 



Section of Kolar 
or Masticating Tooth 




Bone of Jaw -J 



A B 

A, structure of a permanent grinding or molar tooth; B, structure of a 
front incisor or cutting tooth. 
14 



210 PHYSICAL DEFECTS 

work was so successful that the following year money was 
appropriated to pay three dentists seven hundred dollars 
each per year. The central clinic at City Hall was supple- 
mented in 1912 by a downtown school clinic. 

In 1910 the equipment of the Dental Dispensary and the 
organization of the volunteer corps of operators and inspec- 
tors were advanced to the point where the treatment of 
the teeth of school children could be begun. In the dis- 
pensary in City Hall there were two chairs in service, and 
by the end of the year, the equipment was completed by 
providing a third chair for administering nitrous oxide 
gas in such cases as required unavoidable extraction. One 
afternoon of each week was assigned for extractions, and 
on all other days the third chair was used for operations 
involving means of preserving teeth, which is the primary 
object of the dispensary. 

The equipment is modern and complete. Especial atten- 
tion was given by the committee to devising forms and 
records with provisions for securing uniform procedure on 
the part of the numerous dentists who volunteered for the 
work. 

The examination chart on pages 211 and 212 shows a 
specimen of the chart used and the methods of recording 
conditions found upon inspection of the teeth. These 
examination charts and also the clinical charts are printed 
on five by eight card-board in red ink to permit the 
legibility of black pencil marking. 



THE TEETH 



211 



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212 



PHYSICAL DEFECTS 



THE TEETH 213 

Special Instructions. — The charts shall be marked in 'pencil 
in order to avoid the accidental marks from blots if marked 
in ink. 

The essential points required shall be supplied by marking 
on the chart of the teeth the extent and position of the decay, 
the teeth lost, not erupted, extracted, or requiring extraction, 
and those accompanied by fistulas. Special care shall be 
taken that the number of teeth actually present is accurately 
shown on the chart, as otherwise errors may arise as to 
the frequency of the presence of temporary teeth in the 
adult. 

Enter age of child examined, in years and months, on date 
of examination. If the age is doubtful, place an interroga- 
tion mark after the figure on the reputed age. Carefully 
ascertain the general information called for and note the 
following instructions for marking the examination chart: 

Temporary Teeth. 1. Shade in roughly on each tooth 
diagram the extent of the caries affecting each tooth. (See 
specimen case 7, 8, 9, etc.) 

2. Teeth lost should be indicated by a horizontal line 

drawn across the diagram thus: -(See specimen case 

•2, -4, -1, -3, etc.). 

Permanent Teeth. 1. Teeth not yet erupted should be 
indicated by a vertical line drawn through the diagram of 
such teeth, thus: I. (See specimen case 6, 8, 10, etc.) 

2. Teeth which have been extracted should be indi- 
cated by a St. Andrew's cross, thus: X. (See specimen 
case 11.) 

3. Teeth which should be extracted should be indicated 
by an oblique line, representing one limb of the cross thus : / 
(See specimen case tt.) 

4. Shade in roughly on each tooth diagram the caries 
affecting each tooth. 



214 PHYSICAL DEFECTS 

5. Any fillings present may be indicated by a simple 
outline on the appropriate tooth diagram. (See specimen 
case 12.). 

6. Note on the chart, over or under the appropriate 
tooth diagram, any existing fistulous opening, thus : 0. (See 
specimen cases -"s and tt). 

If, upon investigation, the case is found to be a proper 
one for dispensary treatment, the following certificate is 
used and the necessary treatment is given: 

City of Philadelphia. 
Department of Public Health and Charities. 

BUREAU OF health. 

Dental Dispensary, 

Room 706, City Hall. 

Philadelphia 191 

This is To Certify that age i.. 

Residence School 

District... Grade 

is in need of dental treatment and the parents are unable 
to pay for the same. 



Inspector. 



Principal. 



Present this Certificate at Room 706, City Hall. 
Office Hours: Monday to Friday, 9 A.M. to 4 P.M. 
Saturday, 9 A.M. to 12 noon. 

Engagements with a child at the clinic are recorded 
on one of the following blanks, which is to be shown to the 
teacher and brought back to the clinic at appointed time: 



THE TEETH 215 

City of Philadelphia, Department of Public 
Health and Charities. Bureau of Health. 

Dental Dispensary : Room 706, City Hall. Branch : South- 
wark School, 9th and Mifflin Streets. 

Has an Appointment for Attest 

When present 

Monday at 

Tuesday at 

Wednesday at 

Thursday at 

Friday : at 

Saturday at 

Bring This Card with You. 

Discharged for Months 

Show this card to the teacher. 

Direction for Brushing the Teeth. 

Turn out about a teaspoonful of precipitated chalk into 
the palm of one hand, touch the chalk with the wet brush, 
and brush (1) up and down the inside of the lower front 
teeth, (2) the right and (3) the left side of the lower back 
teeth, (4) inside of the upper front teeth, (5) right and (6) 
left side of the upper back teeth, (7) outside of all teeth, 
upper and lower, brushing up and down. 

To clean each of these seven divisions, jBrst wet the brush 
then dip it in the powder in the hand. 

Brush the teeth at night and rinse the mouth night and 
morning with a teaspoonful of table salt dissolved in a 
tumbler of warm water. 

Reports of the work performed each day are kept on blank 
forms similar to the one here reproduced, and weekly and 
monthly reports rendered to the chief of the bureau. 



216 



PHYSICAL DEFECTS 





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THE TEETH 



217 



Eruption of Teeth. — ^The table below gives the approximate 
time for the teeth of the two sets to erupt, but in individual 
cases they may come in earlier or later than the dates 
given, as these dates are only an average. 



Decidttous or Baby Teeth. 



Tooth. 


Erupts. 


Is Shed. 


Central incisors 
Lateral incisors 
Cuspids 
First molars 
Second molars 


6th to 8th month About the 7th year 

7th to 9th month About the 8th year 

17th to 18th month About the 12th year 

14th to 15th month About the 10th year 

18th to 24th month 11th to 12th year 




Permanent 


Teeth. 


Tooth. 






Erupts. 


Central incisors 
Lateral incisors 
Cuspids 
First bicuspids 
Second bicuspids 
First molars 
Second molars 
Third molars 




7th to 8th year 
7th to 8th year 
12th to 13th year 
10th to 11th year 
11th to 12th year 
6th to 7th year 
12th to 14th year 
17th to 26th year 



The first permanent tooth to erupt is the first molar, 
which is the sixth tooth from the middle line of the face 
and makes its appearance when the child is about six years 
of age. As this tooth is being formed in the jaw from the 
time the child is born, some of the diseases of children, such 
as scarlet fever or measles, may result in its being faulty 
in formation. In any event, it comes into the mouth at 
such an early age that parents should give it particular 
attention. This is especially necessary, as it is probably 
the most important tooth in the mouth so far as the future 
health of the child is concerned. 

Shape. — If the permanent upper incisors are somewhat 
rounded and peg-like, tapering from the gums, with a dis- 



218 



PHYStCAL DEFECTS 



colored notch on the edge, they suggest syphilis. Keratitis 
and middle-ear disease associated with such teeth confirm 
such a diagnosis. 

Fig. 50 



UPPER JAW 




LOWER JAW 



Ordinary healthy second set of teeth, showing how the lower fit into the 

upper teeth. 

Fig. 51 




UPPER JAW 

Showing front teeth and places between teeth where food has collected and 

led to decay. 

Fig. 52 



UPPER JAW 




LOWER JAW 



Front view of the upper and second lower teeth, showing how the teeth 
do not meet in front as the result of thumb-sucking, the use of rubber teat, 
or comforter. 



Loosening of the teeth, associated with spongy, bleeding 
gums, may be caused by lack of proper hygiene of the mouth, 



THE TEETH 



219 



a mercurial stomatitis, pyorrhea alveolaris, possibly rheu- 
matic, or it may be caused by scurvy or purpura. 

Stomatitis, inflammation of the oral cavity, with or with- 
out carious teeth, is generally due to lack of proper hygiene 



Fig. 53 



iiil^PER JAW 




LOWER JAW 



Side view of second set of upper and lower teeth, showing how the I'ront 
upper teeth may project, as the result of thumb-sucking, the use of the 
rubber teat, or comforter. 

Fig. 54 




Showing natural crevices in healthy back teeth in which food collects 
and so leads to decay and formation of cavities. A bicuspid has at some 
time been extracted on the right side and nature has filled the gap. 



of the mouth. This may vary from a simple redness with 
a few small ulcers to a gangrenous state of the mucous 
membrane. 

The teeth are supposed to have their cutting edges meet 
the similar surfaces of the teeth in the other jaw, when the 
jaws are closed. There should be no large spaces between 
adjoining teeth. Irregular teeth not only mar the appear- 



220 



PHYSICAL DEFECTS 



ance of the individual, but the deformity detracts from their 
usefulness. Chewing may be interfered with and speech 
affected. There is also an increased liability to decay. 

Irregular teeth are caused by heredity, certain habits 
in childhood, such as sucking the thumb or comforters; 
diseases or growths in the nasopharynx, which may alter 
the shape of the mouth; and too early loss of temporary 
teeth by neglect and extraction. Each of the deciduous 
or temporary teeth is succeeded by a permanent tooth, 

Fig. 55 

and are complete at two and a half years. 
Chewing or Masticating Teeth Canine Incisors or 
Tooth Cutting Teetli 



Wisdom Tooth 

comes at from 

18th to 25th 

year. 



Wisdom Tootli |»,~_ 




Chewing or Masticating Teeth 



Incisors or 
Canine Cutting Teeth 
Tooth 



Side view of upper and lower permanent teeth of right side. They begin 
to appear at six years of age and are complete at twelve, with the exception 
of the wisdom teeth which appear at from sixteen to twenty-five years of age. 



and their relation in the jaw makes it necessary for the 
temporary tooth to remain until the permanent one is 
about to erupt. 

Decay, or carious teeth, is due to neglect. When the signs 
and symptoms of decay are ignored, the pulp becomes 
involved, the tooth is destroyed, and infection may take 
place, attended by acute pain and swelling of the face, due 
to an abscess formation. 

A warning should be given where an abscess has formed 



THE TEETH 



221 



from a decayed tooth, not to poultice or apply heat to the 
face, as the abscess may rupture on the face and leave an 



Fig. 56 




Teeth of a child between six and seven years old. Bone removed to show 
second set forming. 



unsightly scar after healing. Warm solutions in the mouth 
are more comforting, and if the pus comes to the surface, 
will cause it to discharge on the mucous surface. 



222 PHYSICAL DEFECTS 



THE TREATMENT OF CHILDREN'S TEETH.i 

In any community where dental organizations exist avail- 
able for public service, it would be a wise plan to first 
examine all the children subject to prospective treatment 
for the purpose of filling the first permanent molars before 
the pulps become involved. 

When it is considered that at this age, with partially 
calcified roots, the permanent usefulness of these teeth 
depends on a live pulp, and when the preservation of this 
organ vital or its exposure may rest on the narrow margin 
of a few days, the demand for action is apparent; that it 
may be saved for life, before exposure, by one or more simple 
operations requiring a few minutes' time as against an 
operation after exposure requiring superior skill, several 
hours' labor, and less promising results. 

We may be justified in trusting to nature to overcome the 
possible consequences to the permanent teeth from the pre- 
mature loss of the temporary ones, but there is no remedy 
for the results attending decayed and neglected first per- 
manent molars. 

The choice of filling material for simple cavities in these 
teeth is no problem. Pink gutta-percha base plate serves 
every purpose; even though it be less durable than amalgam, 
its superior insulating property permits the pulp uninjured 
by thermal shock to continue its formative function. Fur- 
thermore, if decay exist at all at this age, it indicates a 
period of susceptibility due to a contributory constitutional 
cause, and this material offers the best protection during 
this time. 

iBy P. B. McCuUough, D.D.S., Philadelphia, chairman of the committee 
in charge of the Dental Dispensary, Department of Public Health and 
Charities. 



THE TREATMENT OF CHILDREN'S TEETH 223 

When the filHng has worn to such an extent as to require 
a new one, choice of material should be governed by the 
prevalence or absence of susceptibility to decay. If the 
former state obtains, it is well to repeat the gutta-percha; 
if the latter, amalgam may be substituted. In every case, 
phenol should be the last application preceding the filling. 

In cases of extensive decalcification of the permanent 
molars without pulp involvement, copper cement or zinc- 
phosphate is to be preferred. For fear of operative exposure 
all decalcified dentin need not be excavated; alternative 
is to be had in germicidal agents. Extreme care is required 
to preserve the pulps in these teeth alive, the permanency 
of the filling being a lesser consideration. 

As one internal administration of a drug will not cure a 
disease for which it might be specific, so does repeated filling 
help a sick tooth. 

After the cavity has been prepared, observing the limita- 
tions stated, it is saturated with phenol, dried, then silver 
nitrate, then the cement. 

Capping of an exposed pulp can, at best, be regarded as a 
tentative procedure. All that can be expected of the material 
is that it be non-irritating, germicidal, with some lasting 
antiseptic property, and have body. Such a combination 
we have in a paste of phenol, iodoform, and zinc oxide. 
Cement is the best filling over this cap, because its dura- 
bility is limited and, when refilling is indicated, opportunity 
is given to see the result of the treatment. 

Whether this capping material or any other of the known 
combinations is used, there is one of three possible results: 
First, if the extent of pulp infection is such that it is not 
sterilized by the treatment, pain within a few days following 
the operation will require the removal of the filling and 
justify devitalization. Second, if structural change of the 



224 PHYSICAL DEFECTS 

pulp has been such from the exposure that repair does not 
follow, then the pulp slowly dies, without pain, and, as a 
rule, without suppuration within the life of a cement filling. 
Third, rarely the pulp may and has continued vital under 
this treatment, sealing the exposure with calcific deposit. 

Arsenic, a most valuable agent, need not be used to devi- 
talize pulps in young teeth. The secret of pulp extirpation 
withoug pain consists in understanding the time required 
to produce desensitization. To this end, cotton wet with 
phenol, touched to iodoform and sealed on the exposure 
with temporary stopping to stay a few days or a few weeks, 
will be found effective. 

Extension of the cavity, for direct access to canals, is 
necessary to thoroughness, and a reamer used to enlarge the 
mouths of the latter only. The use of any other engine tool 
is unnecessary and unmechanical. With smooth broaches 
and sodium-potassium results are obtained heretofore 
impossible. 

The distal canal of the lower and the palatal canal of the 
upper molars are best filled with pink gutta-percha base 
plate. Out of regard for accuracy, a set of canal pluggers 
has been designed of graduated sizes so that, when a large 
foramen presents, it may be sealed with precision. Beginning 
with a small plugger, successive sizes are tried until one is 
reached that will not pass the opening, then the next size 
larger is selected to place the gutta-percha seal. 

The distance from the end of the plugger, when in place, 
to the foramen is measured, and a point rolled of such 
length and uniform diameter, the plugger heated and touched 
to the point, the canal flooded with alcohol, dried (not 
desiccated), then moistened with phenol, which allows 
the softened gutta-percha to slide along the walls of the 
canal without bending. When cajuput or eucalyptol is 



THE TREATMENT OF CHILDREN'S TEETH 225 

used, it is better to place the drug in the canal rather than 
dip the point in the solvent. 

Oxychloride of zinc, when properly made, is a superior fill- 
ing for the mesial canals of lower and the buccal canals of 
upper molars. It can be pumped to place with smooth 
broaches, and pressed with cotton pledgets without danger 
of forcing it through these canals, when normal. A drop 
of glycerin at the time of mixing retards setting. 

For the treatment of infected root canals formaldehyde 
is the most potent germicide, but, as such, it requires judi- 
cious handling. A paste made of three grains each of iodo- 
form and precipitated chalk, with water and alcohol and one 
drop of formalin, is as strong as this gas can be used not 
to cause peridental irritation. This mixture can be readily 
pumped into canals where it would be difficult to place 
cotton threads. 

The object of the combination is primarily to provide 
convenient distribution of the formalin, the iodoform as a 
more lasting antiseptic and the chalk as a convenient vehicle. 

Odontalgia. — ^With time, skill, and care, it may be said, 
as general statements go, that every operation we are called 
upon to perform for children can be done without pain, 
except extracting, and, correlatively, it is equally true that 
it is never necessary to extract to relieve toothache. 

The first step in a contemplated remedy is diagnosis; 
an intelligent attempt to relieve pain is possible only after 
an understanding of the cause. Toothache is a symptom 
of pulpitis or pericementitis. If it be the former, the cavity 
is to be closed; if the latter, it is to be opened. Phenol is 
a superior remedy for producing instant relief for pulpitis. 
Opening the pulp cavity in pericementitis usually afford 
relief in twenty minutes; occasionally, the relief is immediate. 

Soreness to pressure, usually pathognomonic of putre- 
15 



226 PHYSICAL DEFECTS 

scent pulp, should be regarded as positive only after it is 
proved, for occasionally we find pus in the pulp cavity 
while the pulp is still sensitive, with pericemental involve- 
ment from extension of the inflammation. In these cases 
relief is obtained by careful extension of the exposure to 
relieve pressure, followed with phenol to stop pain. This 
dressing sealed in for three days usually permits the 
removal of the pulp at the end of this time. 

With pericemental involvement beyond this stage means 
incipient abscess from putrescent pulp, the first indication 
being free vent without attempt to enter canals lest mixed 
infection be forced through. If, after a day, relief from pain 
is not obtained, then partial mechanical cleaning of the 
canals is indicated, followed with the formalin paste and 
temporary seal, the application of formalin to the gum as 
a counter-irritant and the constant use of a capsicum plaster 
or a hot fig. Such procedure is designed as tentative treat- 
ment to abort an abscess, and, while often effective, positive 
prognosis of the immediate outcome cannot be made. 

If the state of development of the inflammation is such 
that resolution cannot be established, then this same treat- 
ment helps suppuration without causing it. The patient 
should be seen daily, and if pus does not result within three 
days from the appearance of the swelling, then the canal 
dressing should be changed at once; again in twenty-four 
hours, then in two days, and the last treatment left for 
several days as a precautionary measure before filling. 

The Temporary Teeth. — Cavities in the temporary molars, 
more frequently than in the permanent ones, are in the proxi- 
mal surfaces, and, regardless as to whether the occlusal 
surfaces are involved, they should be so extended for direct 
access. It will, as a rule, be found the best practice to fill 
these cavities with amalgam that the one operation may last 



THE TREATMENT OF CHILDREN'S TEETH 227 

the life of the tooth. Time is saved by using a matrix. 
Tin-foil burnished over the surface of the filling, extracts 
excess mercury and speeds hardening. Finishing beyond 
removing excess material, as the gingival margin and clear- 
ing the occluding tooth, is unnecessary. Phenol should be 
the last application before filling. 

Apparently reflecting their destined transitory purpose, 
pulps in these teeth show less resistance than those of the 
permanent ones, together with the fact that the pulp is 
sooner involved by decay explains why capping is less 
frequently indicated. 

It may, however, be the means of prolonging the time for 
a more extensive operation, and, for this reason, serve an 
important purpose in dental child-training because of the 
painlessness of the procedure. Again, in the event of an 
operative exposure the material given being both anesthetic 
and antiseptic, prevents postoperative pain and suppuration. 
At the time when the wearing of the cement filling would 
require further treatment, the course to be pursued would 
be governed by the time yet remaining for the permanent 
successor to erupt. 

When devitalization is required, the same method recom- 
mended for the permanent teeth will be found effective; 
subordinating quick results to the avoidance of pain. The 
mechanical and chemical treatment of the canals is neces- 
sary as before stated. With the superior virtues of sodium 
potassium, sulphuric acid should not be used, Oxychloride 
of zinc, to the powder of which is added iodoform at the 
time of mixing, is pumped in all the temporary root canals, 
observing care to avoid pressure. As it is to be expected 
that such work would only be spent on a tooth having several 
years to remain, amalgam becomes the logical finishing 
filling. 



228 PHYSICAL DEFECTS 

A Last Resort to Avoid Extracting. — It is of daily occurrence 
among neglected little children to see a temporary molar 
pulpless, with pericemental attachment that would be 
painfully resistant to the forceps, with one year or more 
remaining before the time for the normal appearance of its 
permanent successor, with the limitations of time and poverty 
curtailing the to-be-desired remedy and pity forbidding 
extracting. 

More than this, possibly all of this first set with ragged 
enamel margins surrounding cavities housing infectious 
bacteria, unchanged, by mastication, or washed by the oral 
fluids, until from decalcification, pericemental and alveolar 
necrosis all are lost like sequestra. A condition causing 
septicemia oftener than is recorded demands quick 
remedy. 

We all have seen crownless roots in the mouth, even with 
the gum line without abscess or noticeable pericemental 
infection, lost after years by slow decalcification of the 
exposed surfaces, atrophy, and exfoliation without the sign 
of pus. 

Observation of this fact suggested the feasibility of arti- 
ficially producing this condition as a measure of last resort 
to prevent the consequences resulting from premature 
extracting. 

One preliminary requisite for alveolar abscess is the lodge- 
ment and protection which a partially enclosed carious 
cavity affords to pus-producing bacteria — it is the mechanical 
requisite — therefore, with this removed, we have destroyed 
one of the essentials necessary for the production of pus, 
and happily, as with all our work, some trust must be 
given to nature's support, so does it follow here. 

With a large corundum stone revolving across the portion 
of the tooth to be removed, the buccal and lingual walls 



ORTHOPEDIC DEFECTS 229 

are ground away to the gum line, leaving the likely one 
sound wall remain, the walls of the pulp cavity are burred 
out to diverge from the floor, the fistulse irrigated with 
germicides, the exposed tooth surface treated with silver 
nitrate and the child told to wash the mouth with salt 
(sodium chloride). 

The remaining mesial or distal wall, if any remains, in 
time breaks away, the free opening permits changes of the 
lodging food debris by mastication and free access of the 
changing fluids in the mouth, the canal mouths offer less 
resistance to the egress of the products of fermentation 
than does the apical ends. 

By this simple and quick mechanical measure the forma- 
tion of pus is stopped, space is conserved for the permanent 
teeth, and the operation is painless. 



ORTHOPEDIC DEFECTS. - 

The grosser orthopedic defects can generally be detected 
as the child walks toward the examiner, but owing to the 
fact that it is forbidden to undress a child for examination, 
the moderate defects are most likely to be overlooked. 
Of the more apparent defects, coxalgia or hip deformity, 
which may be due to injury or disease around the joint 
(generally tuberculosis), may be observed by the charac- 
teristic gait. Defects such as wry-neck or torticollis are 
apparent to even a non-medical examiner, as also are knock- 
knee (genu valgum), eversion of knees; inversion of knees 
(genu varum); and club-foot (talipes). 

If a curvature of the spine is well-marked there is little 
need for a special examination, but where a moderate amount 
of defect exists, diagnosis can be made only by undressing 



230 PHYSICAL DEFECTS 

the child. Before diagnosticating spinal curvature, the 
examiner should be assured that the manner of dress is not 
simulating a defect. The author has frequently observed a 
foreigner who seemed to be a hunchback, but the supposed 
defect proved to be only a bunch of clothing huddled on the 
back drawn up by a pair of tight suspenders on a boy or 
ill-fitting clothing on a girl. Where a child comes from a 
cold climate it is not unusual for it to be clothed in three 
or four shirts and as many petticoats and dresses. 

Scoliosis. — Scoliosis, or abnormal curvature of the spine, 
is often found among school children. Investigations by 
authorities in the United States and other countries show 
this defect to exist in varying degrees in about 20 per cent, 
of the school population. The percentage is slightly greater 
among boys than girls. The common type of school deform- 
ity is a functional or false scoliosis, and not a severe struc- 
tural form (Figs. 58 and 59). There exists a moderate 
degree of convexity toward the left. These cases are mostly 
due to faulty positions in standing or sitting. 

The other variety or degree of scoliosis is readily diagnosti- 
cated and includes marked structural changes and deformities. 
It occurs where a child is weak, poorly nourished, and lacks 
bone and muscle resistance, in addition to faulty posture. 
Diseases and defects which reduce the vigor and health of 
the child, decrease its resistance to abnormal and long-con- 
tinued strain, and predispose the child to spinal troubles. 
Habitual bending over desks while reading or writing pro- 
duces a posterior curvature or kyphosis of the spine. If a 
twisting of the body is added to this faulty posture there 
results a scoliosis or lateral curvature. There can be no 
doubt that faulty school furniture, with improperly adjusted 
seat and lack of support for the back, is an important factor 
in causing spinal deformities. 



ORTHOPEDIC DEFECTS 



231 



Fig. 57 




Typical case of left scoliosis ; physiological curve. 



232 



PHYSICAL DEFECTS 



Fig. 58 




Antero-posterior position, showing physiological curve. 



ORTHOPEDIC DEFECTS 



233 



Fig. 59 



Other Defects. — Kyphosis is a posterior curvature of the 
spine with the convexity directed backward. It may be due 
to rickets or long-continued ih- 
ness. The examiner should bear 
in mind that there may exist 
normally an unusual prominence 
of the seventh cervical or eighth 
and ninth dorsal vertebrae. 

Lordosis consists of a curva- 
ture with the convexity forward 
noticeable in the lumbar region. 

Stoop ' shoulders or round 
shoulders is chiefly a defect due 
to habit, though augmented by 
poor physical condition and mal- 
nutrition. The habit may be 
acquired by stooping over to 
read and write when defective 
vision is present. Persistent 
training is required for its cor- 
rection, and in addition, braces 
are often needed. Tonics, nour- 
ishing food, and fresh air aid in 
the treatment. 

Marked orthopedic defects are 
often acquired in infancy, due to 
rickets and other diseases affect- 
ing nutrition. These cases require 
surgical interference. Curvatures 
of the spine are often caused by 
habits of faulty posture in stand- 
ing or sitting, desks and chairs not suited to the size of the 
child carrying heavy loads on one shoulder, etc. Care should 




Marked lateral deviation of 
the spine, with rotation. De- 
formity at the eighth dorsal 
vertebra. (Whitman). 



234 



PHYSICAL DEFECTS 



be exercised in the hygiene of the school-room with relation, 
to the posture assumed when sitting or standing. Proper 
desks and seats should be supplied and the teacher should 
at all times correct faulty posture. Physical exercise as 



Fig. 60 




A marked case of asymmetry and spinal curvature. 



practised and taught in most schools accomplishes much in 
encouraging standing erect, and some of the exercises are 
important in the correction of moderate degrees of spinal 
curvature and deformity. 



SKIN DISEASES 235 

SKIN DISEASES. 

A knowledge of dermatology, especially the differential 
diagnosis, is essential for the proper examination of school 
children. Almost any of the many diseases of the skin may 
be found among the pupils, but in the following pages the 
field is covered only so far as it is of interest and value to 
the school examiner, and unnecessary detailed descriptions 
of the diseases omitted. It is the duty of the school phy- 
sician to recognize every eruption on the skin, to promptly 
eliminate the contagious from the non-contagious, and to 
protect the school from an epidemic of an infectious disease 
or a contagious skin disease. The spread of contagion in 
a school may reflect upon the efficiency of its attending 
inspector, and he must, therefore, be mindful of those erup- 
tions which are secondary to and symptomatic of the 
exanthemata. 

Most of the symptoms are objective and visual, and the 
diagnosis must generally be made by the eyesight alone. 
It is impossible to represent in words the manifold impres- 
sions of the characteristics, color, and shape of the various 
lesions which should be seen and studied to admit of diag- 
nosis of similar cases. 

For the purpose of school inspection, skin diseases may be 
classified into: 

1. Systemic contagious diseases, including measles, scarlet 
fever, smallpox, vaccinia, chickenpox, and German measles. 

2. Non-systemic contagious skin diseases, including ring- 
worm of scalp, ringworm of body, favus, scabies, impetigo, 
and pediculosis. 

3. Non-contagious skin diseases, of which the most fre- 
quent are eczema, acne, herpes, urticaria, alopecia, carbun- 
cles, furuncles, and psoriasis. 



236 



PHYSICAL DEFECTS 



Contagious Diseases. — The group of systemic contagious 
diseases belongs rather to the domain of general medicine 
than to dermatology and has been considered in the part 
on "Infectious, Contagious, and Communicable Diseases." 



Fig. 61 




Ringworm of scalp. (From Dr. G. H. Fox's Atlas of Skin Diseases.) 



In making a diagnosis the inspector should consider the 
character of the eruption, the lesions, their location and 
distribution, the history and mode of invasion, and the 
association of systemic symptoms. 

Ringworm of the scalp is a parasitic disease of the scalp 
characterized by circular or diffuse, inflamed, scaly patches, 
with diseased and broken-off hairs. It is of common occur- 
rence in children, and generally covers an area of not more 
than one or two inches. At the margins of the patch are 
found inflammatory papules, vesicles, and pustules, and the 



SKIN DISEASES 237 

broken-off hairs are covered with a grayish dust. Ringworm 
can be diagnosticated from favus by the absence of the 
pecuhar sulphur-yellow, cup-shaped crusts. 

Ringworm of the body occurs most frequently on the 
arms, face, or neck. It begins as a small, circular, slightly 
raised, circumscribed area, which enlarges peripherally and 
the margins remain red and composed of papules and vesi- 
cles covered with a fine scaling, and the centre gradually 
fades. It must be distinguished from eczema and psoriasis. 

Fig. 62 





Ringworm of the body. (From Dr. G. H. Fox's Atlas of Skin Diseases.) 

Favus is a contagious parasitic disease most often on the 
scalp. Its characteristic form is lemon or sulphur-yellow, 
cup-shaped crusts, firmly adherent to the scalp, and when 
they come away there remains a deep pitting from loss of 
tissue. There is a peculiar odor, sometimes termed "mouse 
odor," which accompanies the disease. 

Scabies, or "itch," is a contagious animal parasitic disease 
characterized by itching and various lesions of papules, 
vesicles, pustules, crusts, and, excoriations chiefly on the 
hands, abdomen, and inner aspect of the thighs. The itching 
is most severe at night, because the parasite is more active 



238 PHYSICAL DEFECTS 

at that time. The burrows appear as white or yellow 
streaks, about one-quarter inch long, and dotted with 
minute black spots. 

An itching rash on the back of hands with scratch marks 
and burrows between the fingers should suggest scabies. 

Fig. 63 




Impetigo contagiosa. (Hyde.) 

When possible it is well to confirm the diagnosis by examin- 
ing the lower abdomen and inner parts of thighs for a similar 
rash. The inspector should inquire if others in the family 
have the disease, and examine all children of that family 
who attend school. 



SKIN DISEASES 239 

Impetigo contagiosa is an acute inflammatory contagious 
disease appearing in isolated patches of vesicles, pustules, 
and crusts, generally on the face. It is to be distinguished 
from eczema. 

Fig. 64 




Pediciilosis capitis. (Courtesy of Dr. S. I. Rainforth.) 

Pediculosis of the head is characterized by the appear- 
ance on the scalp of the live pediculus and its ova, and a 
secondary eczema and dermatitis, which may spread to the 
face and neck. If unattended, the hair becomes matted 
together into a foul-smelling, decomposing mass of crusts 
and dirt. The vermin are freely communicated in the schools, 
especially where there is an interchange and close contact 



240 PHYSICAL DEFECTS 

of hats and wraps. It is the most common of all skin diseases 
and the examiner must not be deceived in diagnosticating 
the disease, by the fact that the children are clean, well- 
dressed, or from so-called good families. Suspicions should 
be aroused whenever there exists a rash with scratch marks 
on the back of the. neck or parts of the body .where cloth- 
ing comes in close contact, as on the shoulders. The vermin 
and nits are readily seen among the hairs. 

On the body, pediculosis appears as minute red dots 
surrounded by a wheal, together with crusts and scratch 
marks, due to the itching. The location of the lesions on 
the neck, waist band, shoulders, buttocks, and thighs and 
the finding of the parasite distinguishes the disease from 
eczema and other affections. 

Treatment. — All children with an eruption suspicious of the 
acute infections, and any contagious skin disease not under 
treatment, should be excluded from school. Scabies should 
be excluded until cured; pediculosis, until no vermin can be 
found. Impetigo and ringworm may be allowed in school 
if under treatment and painted with tincture of iodine or 
collodion. Scabies should not be treated at school, but the 
nurse may go to the home and instruct the mother how to 
apply sulphur ointment. Applications on three successive 
days generally make it possible for the child to attend 
school with safety. Care must be exercised that the child 
does not reinfect itself through its clothing, especially 
pockets, or through the bedclothing at home. Both ring- 
worm of the scalp and favus are difficult to treat, having 
a tendency to be chronic. 

Pediculosis should not be treated at school, and as treat- 
ment must take place at home, the parents should be in- 
structed as to the best method of cleaning the scalp. With 
many parents, considerable diplomacy is needed in notify- 



SKIN DISEASES 241 

Ing them of the existence of the condition. Antagonism 
can often be avoided by giving the impression that the 
origin of the contagion rests with some other pupil in the 
class-room, and thus avoid any suggestion of uncleanliness 
in connection with the child under treatment. 

The following circular of instructions for treatment is 
also effective: 

Bureau of Health, 
notice to parents. 

When a pupil of the public school is excluded by the 
assistant medical inspector on account of having an un- 
clean head, the following remedies may be resorted to in 
order to cure the condition: 

Take equal parts of kerosene oil and sweet oil — mix and 
saturate hair and scalp thoroughly with the mixture. Tie 
head in towel and leave it so one night. Next morning 
wash the child's head with hot water and soap, and remove 
all traces of the oil. After thoroughly drying, saturate 
with vinegar, separating hair into strands, and brush with 
stiff brush. 

After such treatment, the pupil may return to school 
and inform the medical inspector what has been done; or 
the parents may send a note, indicating what treatment 
pupil has had. If result is satisfactory, pupil may be 
readmitted. 

Non-contagious Diseases. — ^The non-contagious skin dis- 
eases are numerous and a few, including eczema, acne, herpes, 
and urticaria, are frequently found among school children. 
It is unnecessary for the examiner to be acquainted with all 
of these diseases, as, aside from the discomfort given the 
child, they rarely interfere with its education. Treatment 
should be insisted upon in all cases. 
16 



242 PHYSICAL DEFECTS 

DISEASES OF THE NERVOUS SYSTEM. 

The medical examiner of school children may diagnos- 
ticate only those diseases of the nervous system which have 
characteristic symptoms, such as chorea or epilepsy. Un- 
usual nervousness or lack of nerve control cannot be diag- 
nosticated by a mere inspection, as it is natural for some 
normal children to be unduly nervous when appearing 
before a stranger. This is especially so when the child 
knows it is a physician whose purpose is to examine him. 
In these cases the diagnosis by an observing teacher is of 
more value. If the inspector sees a child in a paroxysm he 
may diagnosticate epilepsy, otherwise the history of the case 
as given by teacher and child is sufficient evidence. Chorea 
shows some symptoms most of the time, while hysteria 
shows symptoms when watched and must be caught off 
guard. 

Epilepsy consists of periodical paroxysms of convulsive 
attacks with a loss of consciousness. These paroxysms 
vary in frequency and severity. The cases vary from the 
mildest attack of "petit mal" to the severe "grand mal." 

These cases are dangerous in a public-school room, not 
only because they upset the discipline of the class, but on 
account of the danger of a child falling and receiving an 
injury during an attack. A case with frequent attacks is, 
therefore, sufficient cause to exclude a pupil from school. 

The cause of epilepsy may be syphilis, traumatism in rare 
cases, reflex irritation from genital organs, masturbation, and 
eye-strain. Heredity undoubtedly plays an important role. 

Several investigations have shown that errors of refrac- 
tion and muscular eye trouble are found in a large percent- 
age of cases of epilepsy. While this does not necessarily 
mean that these errors are the cause of the disease in all 



SYSTEMIC DISEASES 243 

cases, it is logical to infer that the ill effects on the nervous 
system, especially in children, are an important factor. 

Every case of epilepsy should receive a thorough system- 
atic examination of the eyes, not only for refractive errors, 
but muscle unbalance, and it is the duty of the medical 
officer and teacher to see that parents obtain such an exami- 
nation and the proper treatment. A number of cases have 
been reported cured by such treatment. 

Chorea, commonly known as St. Vitus' dance, is frequent 
in children and while hereditv is an important factor, the 
general history may show some previous injury, shock, or 
fright, reflex irritation from the genitals, intestines, den- 
tition, or eyes. The disease may be acquired by imitation. 
Therefore, in chorea, epilepsy, and other nervous diseases 
the eyes should be examined under a mydriatic. Habit 
spasm, consisting of gestures, shrug of shoulders, winking 
of eyes, or grimaces, may be the remains of a previous 
attack of chorea. 

Hysteria is rare among school children until puberty or 
after the age of twelve. Imitation may be found in some 
cases of hysteria. The symptoms manifested are as varied 
as the number of cases, and may include disturbances of 
the sensory organs, motor apparatus, and even visceral 
disturbances. The absence of any organic disease, and, 
upon careful watching, the discovery of certain symptoms 
characteristic of hysteria, may aid in a correct diagnosis. 



SYSTEMIC DISEASES. 

General Considerations. — It is beyond the scope of medical 
inspection to definitely diagnosticate the diseases which be- 
long to the field of internal medicine. Scientific conscientious 



244 PHYSICAL DEFECTS 

physicians require a thorough examination of a patient before 
rendering a diagnosis. The school doctor in his routine 
work has neither the time, the place, nor the equipment 
for such work, and even though he had the opportunity, 
neither the child nor the school would benefit by the work. 
All cases presenting symptoms of visceral trouble should 
be referred to a physician or dispensary for diagnosis and 
treatment. An old-fashioned "bellyache" by symptoms may 
prove appendicitis on careful examination. The author 
does not approve of the disrobing of a child in school for an 
examination of the chest or abdomen, and the mere placing of 
a stethoscope over the clothing does not warrant a diagnosis 
of cardiac or pulmonary disease. When symptoms exist the 
school doctor should recommend a visit to a physician or 
the dispensary. 

Frequently a child is sent to the school doctor for examina- 
tion of the chest to determine fitness for physical exercises. 
In these cases an examination should be made of the pulse, 
respiration, and heart sounds as revealed by ear alone or 
aided by a stethoscope. All children giving signs or symp- 
toms of cardiac insufficiency should be debarred from 
entering physical contests. Defective breathing, if based 
on mere routine inspection, is very common among 
children, due chiefly to habit. Physical exercise, a part 
of the curriculum of most schools and public playgrounds, 
has done much to eradicate this defect. 

Malnutrition. — Anemia and malnutrition of all systemic dis- 
eases most frequently concern the school inspector. Pallor 
is not always a sure sign of anemia, and a blood examina- 
tion is sometimes needed to confirm the diagnosis. 

Malnutrition may be suspected where a child is pale 
and too weak to properly work and study, but the number 
of cases in the schools is much over-exaggerated. Where 



SYSTEMIC DISEASES 



245 



it is due to lack of food, it is not always poverty, being often 
caused by one or more of numerous home conditions. This 



Fig. 65 




A typical underfed family. A source of cases of malnutrition. 



is more of a sociological than a medical question, and can 
best be solved by the nurse or social visitor going to the 



246 PHYSICAL DEFECTS 

homes, where tact and diplomacy may reveal the cause and 
suggest a remedy. Some of the causes are poverty; late 
hours with loss of sleep; work after school hours, especially 
at night; sleeping in an unventilated room and ignorance 
as to the kind of food suited for a school child. Most of 
these causes can be readily remedied. Poverty should be 
referred to one of the charities, and if late work at night 
is due to need of additional income, this also belongs to the 

charities. 

School Lunches.— The supplying of lunches, consisting of 
soup, crackers, rolls, and pudding to the school children for 
a few pennies, has received considerable impetus in America. 
The success or failure of this undertaking depends altogether 
on the purpose for which it is intended. If these lunches 
represent an effort to conserve the health of children and 
discourage the purchase of impure and unclean candy and 
pretzels, peddled around the school, they are a success and 
a great benefit; but as an aid to poor families, they are a 
failure, because the school children of very poor families 
are not given pennies to spend at school. Should they be 
given these lunches free, the nourishment supplied would 
not be sufficient for the twenty-four intervening hours until 
the next lunch, and from Friday until Monday. ^ Where 
poverty exists sufficient to admit of improper nourishment 
of the children, it becomes a problem for the organized 
charities and not a makeshift for the schools. 

Lunches of milk, eggs, and crackers supplied free to the 
children attending open-air schools is of great value, and 
becomes part of the curriculum of these classes. The nour- 
ishment together with periods of rest and plenty of fresh 
air are the things which improve the child's general health 
and aid in the fight against tuberculosis. This use of school 
lunches is to be highly commended. 



SYSTEMIC DISEASES 247 

Sex Hygiene. — In public elementary schools the medical 
examiner is but rarely called upon to diagnosticate any of the 
acquired venereal diseases. Sometimes a teacher may observe 
a child continually rubbing around the genital organs, and 
seek an opinion of the medical officer. Thus he is occasion- 
ally asked to decide if a child masturbates, and if so what 
action should be taken. A tactful questioning of such a 
child often evokes an answer of itching or discomfort of 
these parts. Lack of cleanliness, possibly the most fre- 
quent cause, and abnormalities, such as adherent prepuce, 
are occasionally found. 

The teaching of sex hygiene in the schools is to be highly 
commended, and talks may be given by the teachers or 
the visiting physician. The author believes that much 
can be accomplished by sensible talks to both sexes, and 
regrets that space will not permit of outlining a course of 
lectures. Especially in the higher grades, talks should be 
given which would teach the dangers and yet not excite 
the curiosity to experiment. 

The author advocates conservative methods of teaching 
sex hygiene to the younger children, who have keen imagi- 
nations and may be more harmed than benefited. Knowledge 
of a subject does not take the place of moral stamina. 
Train the moral character, teach boys purity of thought 
and body, obedience and respect. The child should be told 
what kind of literature to read and to avoid the trashy 
melodramatic stories which now flood the market. The 
school should supply good books for home reading. The 
girl should be taught reserve, modesty of manner and dress, 
and purity. Teach the parents at school meetings the rudi- 
ments of sex hygiene and the relation of moral home life 
to the problem. They should at the proper time teach the 
child what it should know. 



248 PHYSICAL DEFECTS 

Personal Hygiene. — ^The duties of the medical officer in 
the school-room inludes the prevention as well as the diag- 
nosis of disease. He should take every opportunity to teach 
healthful living at home and school and should impress the 
pupils with the need of cleanliness of body, mind, and cloth- 
ing. Method of dress in its relation to health should receive 
his attention, and he should condemn the wearing of corsets, 
tight clothing, tight garters, and heavy clothing suspended 
from the waist instead of the shoulders. His instructions 
should supplement the teacher's course in practical hygiene. 
Where nurses and social visitors are emplo^'ed, they should 
observe on their home visits any refractions from the laws 
of health and try to have them corrected. This is important 
because uncorrected faulty home conditions tend to nullify 
the teachings and efforts at school. Medical inspector, 
nurse, and social visitor should acquaint themselves with 
the laws of their State and city pertaining to housing con- 
ditions and what constitutes a nuisance, and any unsanitary 
conditions of the dwellings or streets should be reported 
to the proper health authorities for their action. 

The teaching of personal hygiene should be an important 
branch in the curriculum of all grades, and should include 
cleanliness, clothing, diet, exercise, proper rest of both 
body and mind, and a strict observance of all rules for 
good health. 

MENTALITY. 

Considerable interest has been shown in the past five 
years in grading children in the public schools according 
to their mental status. The child who was found to be 
below the normal average has been singled out and studied 
for the purpose of adopting some method of educating him 



MENTALITY 249 

with the least amount of interference with school work and 
at the same time to obtain the best results for the individual 
child. 

The precocious or supernormal child is also of interest to 
study, as such children are often responsible for the setting 
of too high a standard for educating the average child. 
The precocious child, naturally of a nervous temperament, 
is pushed forward too fast to the detriment of its physical 
health. 

Classification. — The retarded subnormal and mentally 
defective child for practical purposes may be classified into 
the following groups: 

1. Retarded in one or two subjects. 

2. Subnormal, or a child who is mentally behind the 
average child of the same age. These may also be termed 
"backward" or "dull" pupils. 

3. Mentally deficient or those who are so far behind 
average children of the same age as to be unable to acquire 
an education through the usual channels. 

4. Feeble-minded or those whose mental faculties are 
absent. 

5. Idiot or imbecile, which includes those with no men- 
tality that have associated paroxysms of nervous phenomena 
making them unsafe to themselves and others. 

There are no sharp lines of demarcation between these 
various classes, and they coalesce, making the defect one of 
degree only. The idiot or imbecile cannot be made safe 
enough to place in society or school, and is purely an insti- 
tutional case. Every State should have sufficient institu- 
tional room to care for this class and prevent as much as 
possible their further propagation. 

The feeble-minded through inherited defects of the brain 
should be classed with the imbecile and placed in suitable 



250 



PHYSICAL DEFECTS 



institutions where attempts may be made to give some 
education that may aid the unfortunate in eking out an 
existence. 

Those feeble-minded from an acquired physical defect 
should be placed in institutions where they will receive 
medical care that may correct physical defects and special 
training which may later improve the mental faculties 

Fig. 66 




Feeble-minded children. 



sufficient to enable the child to again be placed with its 
family. These cases rarely take place in society. It has 
been stated that of the inmates of an asylum for feeble- 
minded, 25 per cent, could be made useful men and women 
by correction of physical defects. 

The mentally deficient, the subnormal, and the retarded 
children may be studied together. We should consider the 



MENTALITY 251 

causes, the method of diagnosis and treatment of these 
various defectives. 

Prevalence of Retardation. — ^The number of mental defec- 
tives average about two to every thousand of population. 
The number of subnormal children in the public schools 
varies with the method of examination, the examiner, and 
the standards adopted in determining the defects. The 
report of the Committee on Special Education of the Phila- 
delphia Teachers' Association showed the existence of 11,543 
subnormal children, which was slightly in excess of the num- 
ber of children who were two or more years in grade for the 
year ending June 30, 1908. The number allotted as institu- 
tional cases of feeble-minded was 442, and approximated 
the number three or more years in grade 483. Of a total 
of 881 children enrolled in the special schools, 51 were 
found to be feeble-minded, institutional cases; 538 properly 
belonged to special schools, including incorrigibles and 
truants; 213 were backward and could be taught by special 
instruction. 

Causes of Retardation. — Causes of retardation and the 
subnormal child may be grouped as follows: 

1. Physical defects. 

2. Home surroundings and environments, causing chiefly 
incorrigibles and truants. 

3. Faulty educational methods and inexperienced teachers. 
We must not accept as conclusive evidence of deficiency 

every child labeled defective by a teacher. When a teacher 
asserts that many of her pupils are dull and defective, the 
first thing to observe is the teacher herself and her methods. 
All children are not equally intellectual, and a fair average 
must determine the normal standard. One precocious child 
in a class is apt to increase the teacher's standard, and it 
is inadvisable to use all the available faculty and nerve 



252 PHYSICAL DEFECTS 

force of such a child by frequently advancing it a grade. 
It is far better to devote less time arid teaching effort to 
such a case and more to the less advanced child. The pre- 
cocious child is often one who is receiving care and teaching 
at home. 

An educational system must be elastic enough to reach 
both the mental capacity of the slowly progressing but 
normal child and the precocious one. The teacher should 
study the best methods to impart knowledge to each child 
as an individual, and subjects should be outlined to meet 
the capacity of the average. 

Home Surroundings and Environments. — This is a most 
important causative factor. In suspected cases of mental 
deficiency or backwardness, the physician, nurse, or teacher 
should visit the home and intimately study home conditions. 
Work after school hours and at night, late hours with loss 
of sleep, poverty with insufficient nourishment, worries or 
great responsibility, are some of the many conditions which 
may be revealed. Where parents lack control over a child 
and there is added the influence of morally bad associates, 
there exist two influences that will produce the truant 
and incorrigible child. These children belong in a class of 
their own and the solution is the "Parental School." Before 
disposing of the truant or incorrigible, a thorough physical 
examination should be made and any physical defects 
found should be corrected. One can readily understand 
how a child with some defect, such as bad vision, unable to 
cope with the school problem, willingly drifts into this 
class. 

The public school is no place to attempt to train a mentally 
defective child, and it is no credit to an educational system 
that, by special instruction, succeeds in teaching it, after 
three years' daily training, to place pegs in holes in a board. 



MENTALITY 253 

Such a child never becomes a suitable person for society. 
The object of the school is to fit a child for society and 
citizenship. 

Physical defects causing retardation and subnormal chil- 
dren are malnutrition, exhaustion, and fatigue due to poverty 
or some systemic disease; fatigue due to some home condi- 
tions, as late hours, the use of alcohol, drugs, or tobacco; 
toxemias, such as constipation in children, which may pro- 
duce an auto-intoxication, headaches, loss of sleep and 
nervousness unfitting the child for study; rheumatism and 
uric acid diathesis which may cause nervous, ill-tempered 
children. Syphilis and its effects, especially on the nervous 
system and mentality, is a more frequent cause than is 
credited. Other physical defects are diseases of the nervous 
system, including epilepsy, chorea, and the minor degrees 
of nerve unbalance termed "nervousness." Many of these 
cases are secondary or symptomatic of other defects, such 
as eye, ear, nose, and throat trouble. The nervousness in 
these cases is chiefly a reflex symptom. 

Defective hearing and some of the nose and throat defects, 
such as adenoids and enlarged tonsils, may cause retardation, 
especially when the general nutrition and health of the child 
is impaired. 

Defective vision, hearing, and speech are probably the 
most important physical defects in relation to retardation. 
A child who does not hear well or who cannot see properly 
cannot receive correct impressions on its mental apparatus, 
and therefore must be below the standard of normal children. 

The following case found in one of the public schools 
illustrates the effect of defective hearing: 

A girl, aged fourteen years, two years in the second grade, 
and three or four years in the first grade, was promoted to 
second grade only because the teacher was ashamed to keep 



254 PHYSICAL DEFECTS 

her any longer. This child was found on examination to be 
almost entirely deaf, and also to have a defective speech. 
She deceived the teachers, as well as possibly the parents, 
by guessing at everything said to her, using the movements 
of the lips as a guide. This child on examination was found 
to have a bony growth as well as adenoids entirely cover- 
ing and obliterating the Eustachian tubes. This was the 
cause of both defects, and after operation the child greatly 
improved mentally. 

The following is an example of defective vision: 
Mary D., aged eleven years; nationality, Italian; in this 
country two years; in first grade sixteen months. Sent 
by teacher with this note: "This child cannot talk; appar- 
ently dumb, as it makes signs and motions for everything 
it wants to say, and in answer to all questions." I asked 
the child: "What is your name?" "Mary," she answered, 
in an indistinct whisper. "How old are you?" and several 
other questions, elicited nothing but nods of the head and 
shrugging of the shoulders. The entire time while being 
questioned her face was set in a silly grin, and she nervously 
took hold of my coat, systematically played with each 
button, as though counting. As she had a very marked squint 
I believe her eyes were one of the offending members. She 
seemed to know no letters, or figures, and was unable to 
follow an illiterate test card. I held up two fingers a few 
feet from her, and asked how many fingers? She answered 
"four." To three fingers she answered "six." As this 
was as much as I could get her to answer, I was not prepared 
to say the child saw double. On being handed some pencils, 
she made no effort to count them. Thinking possibly the 
child was unacquainted with our language, I called an 
Italian boy, and had him speak to her in Italian, and asked 
her to answer in Italian. This did not succeed, as she 



MENTALITY 255 

answered but one more question, the name of her father. 
I pointed to her teacher, and asked, "Who is this?" She 
answered correctly and distinctly, but in a whisper. She 
accomplished the same in reference to the principal. 

I wrote on the board the following, and with the child 
seated about 15 feet away I asked her to copy. A normal 
child seated near her was also asked to copy the same, 
which was done correctly : 

The abnormal child made no effort to copy 1, 2, 3, or 4, 
which were drawn 6 inches high and wide. But figures 
5, 6, and 7, which were drawn 3 feet high and wide, were 
copied as shown in figures 8, 9, and 10. The child seemed 
not to see or draw horizontal lines. This case proved a 
marked mental deficiency due to defective vision. 

A o a ^ h A 



12 3 



n 



1 



f) 



10 



Various cities and various countries report propor- 
tions of defective vision ranging from 25 per cent, to 
50 per cent, of the school population. The question is. 
How many of these children with such defects untreated 
can be considered mentally deficient or subnormal? All 
are, for a child that cannot see correctly must get wrong 
impressions and make wrong conclusions. He is usually 
deficient in writing, reading, and spelling. Again, head- 
aches, whether due to an error of refraction or muscular 
unbalance of the eyes, causes a languid nervous, and 



256 PHYSICAL DEFECTS 

inattentive pupil. Cases have been reported in which are 
found good vision, no strabismus, no great refractive error, 
and yet the investigation of the muscular status shows that a 
latent hyperphoria was sufficient to incapacitate the child. 
Most of the statistics of investigation of the condition of 
the eyes of school children are based upon the common 
practice of allowing the pupils to merely read from a Snellen 
test card at a set distance. The child may see the smallest 
letters, and yet it is no sign that the child's vision is normal. 
The range of accommodation in children is great, and while 
one may discover the gross manifest errors, the important 
latent ones are overlooked. The duty of a physician to 
every child which is brought to him suffering from constant 
headaches, nervousness, indisposition, and dulness should 
be thoroughly examined under a mydriatic for both refrac- 
tive and muscular errors, and these should be immediately 
corrected. It remains for the medical profession to overcome 
the widespread ignorance that children should not wear 
glasses because " by wearing them early the child will always 
have to wear them," or "we (the parents) never wore 
glasses." In later life they fall victims to the traveling 
salesman or the fake optician, though even these do some 
good in some cases, in that they correct some of the errors, 
by supplying glasses. The medical profession stands idly , 
by and encourages this fake oculist work by neglecting to 
diagnosticate cases of defective vision in children. 

Realizing that the only true idea of the subject could be 
obtained by the use of a mydriatic, and desiring to obtain 
the worse cases with the most glaring defects, the author 
requested the teachers to send to him those children whose 
work was subnormal, due to a possible defective vision. 
The following statistics of two hundred and fifty pupils 
examined under a mydriatic may prove interesting. All 



MENTALITY 257 

of these cases were carefully refracted with the ophthal- 
moscope and retinoscope. Only twelve ever wore glasses 
before. All obtained the necessary glasses. Number of 
cases of strabismus, 27. Of 185 examined for muscle balance, 
there were 41; hyperopia, 60; myopia, 26; astigmatism, 164; 
hyperopic astigmatism, 86; myopic astigmatism, 45; mixed 
astigmatism, 33; astigmatism with the rule, 80; astigmatism 
against the rule, 67. 

Methods and Records of Examinations. — ^To diagnosticate the 
presence and degree of mental dulness, the examiner should 
take a complete history and make a physical and mental 
examination of the child. The following are the things to 
be considered: 

1. Early physical and mental history from time of birth 
to present (obtained from parents). 

2. Present physical and mental history (obtained from 
teachers). 

3. Mental examination by physician, using Binet's or 
other similar tests. 

4. Physical examination by medical inspector. 

5. Examination of eyes, ears, nose, and throat by 
specialists. 

The early history of the child may furnish valuable infor- 
mation, and should include some history of the physical 
and mental status of the parents. Such information as 
difficult birth, use of instruments, marasmus, convulsions, 
syphilis, inability to walk or talk at usual age may be noted. 

Too much weight must not be given to the assertion by 
teacher or parent that a child is feeble-minded, but full cogni- 
zance should be given to the school records of its education. 
The medical examiner should decide the degree of mental 
dulness, also if an institutional case or one for training in a 
special class, but only after an exhaustive examination. 
17 



258 PHYSICAL DEFECTS 

In a study of retarded pupils the examiner should 
observe : 

Defects in development, size, form, proportion, asym- 
metry, and weight of body. 

Defects in nerve balance or muscle balance. 

Defects in nutrition. 

Physical defects. 

Defects in development: The examiner should weigh 
the child and measure its height and compare with normal 
average for its age. Each part of the body should be scanned 
for lack of development and asymmetry. The head in 
particular may show evidences of poor development, and 
the site of fontanelles, ossification, protuberances, size of 
skull, and general expression of child should be noted. 

Defects in nerve and muscle balance tell much about 
the nervous system of the child. The position taken while 
standing; the extension of the arms in front of the body 
showing drooping of the hands at the wrists, spreading of 
the fingers, nervous tremors, and twitching of the fingers, 
all should receive attention. Likewise, the balance of the 
body and spinal contour while the arms are extended 
should be noted. Results should be tried while the arms 
are extended to the sides. The rapidity or slowness of 
response to the command to extend the arms indicates the 
power of mental reception. The command should be first 
given in words only, then the power of imitation or response 
from vision tried by showing what is wanted. 

The child should stand with feet close together, hands to 
the sides, and eyes closed; then any swaying or inability 
to balance body should be noted. 

Defects of nutrition are told by weight, height, color 
of skin, especially the mucous membranes, and general 
appearances. 



MENTALITY 



259 



Physical defects are taken up under their various head- 
ings, eye, ear, etc. 



Fig. 67 




Testing coordination of nervous system. 

The recording of investigations of backward or mentally 
defective children may be done on blanks similar to the 
following, which was devised by the author and used for 
such investigations since 1904: 

Accurate answers to the following questions are important in the gather- 
ing of statistics of value in the treatment of mentally deficient pupils: 

Name of pupil Address 

School Grade How long in grade 

Age Nationality Color 

How long in school 

This pupil has been considered dull, backward, mentally deficient, or below 
normal 



260 PHYSICAL DEFECTS 

The teacher will kindly answer the following questions : 
Why do you consider him (her) as such? 



In what branches deficient?. 

In what branches proficient? 

Yes or no — Lazy No ambition Mischievous. 

Nervous Inattentive Poor memory. 

Bad morals Truant Violent temper. 



Physical defects noticed by teacher. 



This child has received treatment for 

Has his mental condition improved since treatment? _ 
In what manner? 



In which branches has he (she) improved?. 



Family Histoby. — To be obtained from parent or guardian. 

Health of parent Sisters Brothers . 

Education of parent Sisters Brothers _ 

Mental condition of parent Sisters Brothers _ 

Was birth of above pupil with difficult labor? 

Instruments? Any injury since birth? 

Home conditions: Care Culture Discipline- 
Language spoken at home? 

Is child required to work after school hours? 



Report of Physician. 

Abnormality. Asymmetry. 

Nutrition Trunk 

Weight Arms 

Height , Legs 

Nervous condition Hands 

Coordinations Feet 

Eyes Cranium 

Vision without mydriatic — Forehead 

R. E. L. E. Face 

Vision with mydriatic — Ears 

R. E. L. E. . Eyes 

Color vision Nose . 

Hearing — Lips 

R. E. L. E. Palate 

Throat Tonsils 

Speech Teeth 

Orthopedic defects 

Date Treatment Recommended : 



Non-promotion and Mentality. — ^Numeroiis methods have 
been tried to test the intelligence of children and to sift 



MENTALITY 261 

the backward from the normal. Some large cities have 
prepared a census of their mental defectives and subnormal 
pupils based on the time in grade; age in grade and non- 
promotion. This is not a safe method for diagnosticating 
mental deficiency. In 1909, New York City had 109,440 
children who failed to win promotion in the first term, and 
100,338 in the second term. There were 156,208 "over age" 
pupils in the grades and 20,000 "over age" in special classes. 
Yet it is hardly necessary to say that no one would think 
of classing this large army of overaged and non-promoted 
as mental defectives. 

The causes of non-promotion or two years in grade are 
many, and although the child may be, he more often is not 
a mental defective. When, however, the child is three or 
more years in one grade he is invariably defective. The non- 
promoted child should receive careful consideration by the 
teachers to ascertain the underlying cause, and they should 
be compelled to ascribe a cause for each case. A careful 
record should be kept of the branches in which the child 
fails; those in which he is weakest and those which are 
performed best. The teacher should grade according to the 
child's power of application to the work. 

Causes of Non-promotion: The following classification 
of causes of non-promotion may aid both teacher and 
physician in deciding when non-promotion means mental 
dulness. 

Causes due to School or Teacher: 1. Faulty curriculum. 

2. Lack of success of teacher. 

3. Teacher and pupil incompatible. 

4. Frequent absence of teacher. 

5. Crowded class-rooms. 

6. Standard for promotion too high. 

7. Frequent change of teachers. 



262 PHYSICAL DEFECTS 

Due to Pupil: 1. Frequent change of schools. 

2. Truancy. 

3. Irregular attendance. • 

4. Late entrance. 

5. Ignorance of English language. 

6. Slowness, dulness, inattention, or idleness. 

7. Mental defect. 

8. Physical defects. 

Due to Home Conditions: 1. Poverty causing malnutri- 
tion and necessity to work after school. 

2. Bad environments at home or with associates. 

3. Home cares and responsibility. 

4. Ignorance and carelessness of parents. 

5. Lack of control causing incorrigibility. 

The Binet Test of Mentality. — The most practical tests 
are those devised by Binet, and translated into English by 
H. H. Goddard, of the Vineland Training School for Feeble- 
minded. These tests may be varied somewhat according 
to the originality of the examiner, and in order to obtain 
trustworthy results, he should bear in mind the following 
essentials: First gain the confidence of the child. Do not 
let him know you are quizzing him, but give the impression 
that you are playing with him. Try to find out something 
the child is interested in and draw some conclusions from 
his knowledge on that particular subject. It is not fair, 
for example, to ask an Italian who is but one year in this 
country to designate or pick from a number of coins a 
penny, nickel, dime, etc., and indicate which is of greater 
value. Common-sense on the part of the examiner with no 
previously formed opinion as to the mental capacity of the 
child will invariably net results. A vast store of patience, 
tact, and diplomacy is needed in making these examinations. 
Fear or distrust once established, makes it impossible to 
continue the examination. 



MENTALITY 



263 



The Binet-Simon Measuring Scale for Intelligence. — "Since 
we first translated and published our account of the Binet 
tests in January, .1910, a great stride has been made in the 
use and popularity of this measuring scale. We ourselves 
have tested the questions on four hundred feeble-minded 



Fig. 68 




Outfit for examining backward pupils. 

children and on nearly two thousand normal children. The 
results have been published in the Pedagogical Seminary, 
September, 1910, and June, 1911. 

"As the result of these studies we are able to make some 
suggestions as to desirable changes. It seems worth while 
to include these in the present edition of the tests. 



264 PHYSICAL DEFECTS 

" Experience with these tests has continually reassured us 
not only as to their value, but as to their amazing accuracy. 
Their usefulness as a means of understanding the mental 
development of children is beyond question, and we confi- 
dently believe that the time will speedily come when every 
child in school will be occasionally examined by some such 
method as this with a view of determining his actual mental 
development, and consequently what can be expected of him. 
This, not only for the purpose of segregating and giving 
special treatment to those who are backward or feeble- 
minded, but that we may know those who are especially 
well endowed and those who have average intelligence, so 
that each may receive the instruction that his condition 
requires. 

" In the use of the Binet tests experience has emphasized 
two important dangers or liabilities to error. The one comes 
from the tendency of the optimistic, affectionate teacher 
examining a child from her own room to help too much and 
so credit the child with more than he himself can really 
do. The other is the opposite tendency of the teacher who 
either temperamentally or because of momentary conditions 
is not encouraging, but rather discouraging to the child, 
so that he does not do his best, and, consequently, does not 
get up to the standard of which he is really capable. One 
should never begin the examination of the child with any 
preconceived notions as to what the child is going to do or how 
much he knows. Do not credit a child with a question because 
you feel sure he could do it under other circumstances even 
though he fails now. The probabilities are very great that 
you are mistaken in your estimate and the present result 
is truer than your estimate. 

"As a matter of technique, we find almost universally 
the best method of beginning these tests is to ask the child 



MENTALITY 265 

to look at the pictures. This appeals to almost every child, 
and it also gives the examiner very quickly a clue to the 
grade of the child, especially after one has examined a few 
children and discovers how the different grades answer the 
question, 'What do you see here?' 

"A needed caution here will also illustrate a point that 
applies to a great many of the questions, and that is the great 
care needed in asking the questions. The form of the ques- 
tion is very significant. For example, in showing the pictures, 
the examiner who says, 'What are they doing here?' herself 
answers the very question that we are supposed to determine 
from the child, namely, does he see the action? If you ask, 
'What is he doing?' you compel him to see the action and 
he tells you, 'Mowing grass' or 'Cutting hair,' or whatever 
the picture may be. The question should alwaj^s be in the 
form of 'What do you see here?' Not even 'What is this?' 
or 'What is that?' because that equally determines that the 
child sees a particular thing which again destroys the value 
of the test. And the same caution should be extended to 
many other questions. 

"The form in which the question is asked is of vital 
importance. It is given correctly in the text here and should 
be followed very rigidly except in such cases as it is suggested 
that the form of expression may be simplified to meet the 
child's understanding. 

"Professor Binet has published in the April, 1911, number 
of the Bulletin de la Societe Libre Pour l' Etude Psycho- 
logique de l' Enfant his latest revision of his measuring 
scale. 

"His changes are of three kinds. First, there are the same 
number of questions for every age — except age five, where 
he still has only four. This will obviate a little difficulty 
that was met with in counting up a child's credits. 



266 PHYSICAL DEFECTS 

"Secondly, he has omitted some of the questions that 
were most dependent upon conscious training and education, 
such as the reading and writing tests. 

"Thirdly, he has transposed some of the questions from 
one year to another with the idea of improving the scale. 
With these changes we cannot in every case agree. 

"The results of our experience with the tests on four 
hundred feeble-minded and two thousand normal children 
convinces us that Binet's original scale was quite as correct 
as his new one, but that some improvement can be made in 
certain other questions." 

It is perhaps necessary to remind anyone who is about 
to use the test that in securing responses from children, 
whether in word or deed, many more things are involved 
than the intelligence of the child. The attitude of the 
examiner is all-important. Some questioners do not inspire 
confidence. Then there is the child. Some children are 
timid or bashful. Lastly, there is the relation of the two. 
Always the child must be won. Sometimes it is easy, 
sometimes it is difficult. The questioner should be very 
tactful and careful until he sees that the child is at ease. 
Usually the whole examination can be referred to as a game 
and carried out in that spirit. At all events get down to 
the level of the child. Never tell a child his answer is wrong. 
Always encourage. Always tell him he has done well if he 
has done anything at all, and if he has done nothing pass it 
by as easily as possible. Some children if they have failed 
once and are made conscious of it, will not try again. On 
the other hand, do not insist that he respond, just because it 
seems to you that he must know how. He may not know. 
In other words, when a child fails to reply try to under- 
stand why, and act accordingly. 

The following are the tests proposed by Binet and Simon 



MENTALITY 267 

for each age from three to thirteen. If a child succeeds 
in the tests for his age he is normah If he can succeed only 
in those given for a child a year younger than he, he is 
backward to the extent of one year, and similarly for two 
and three years. If he is more than three years backward 
he is mentally defective. 

To allow for some unevenness in development, Binet 
finds it satisfactory to adopt the following conventions in 
estimating the results: 

A subject has the mental development of the highest 
age for which he has succeeded in all the tests save one, 
e. g., if he has succeeded in all but one test for nine years 
and all but one for ten, he is still credited with the intelli- 
gence of a ten-year-old child. 

One more correction is necessary. Once a child's intel- 
lectual level is fixed, he is to be advanced a year for every 
five higher tests that he has succeeded in and two years for 
every ten tests that he succeeds in, e. g., John is nine. He 
fails in two of the nine-year tests. We should thus class 
him as intellectually eight years old. But he has done three 
of the nine-year tests and three of the ten-year tests, making 
six in all. He is therefore advanced a grade and called 
normal. 

This seems at first sight very artificial and too exact 
to be true, but Binet assures us that he has tested it very 
carefully and finds it amazingly accurate. We proceed 
with the tests. 

Children of Three Years. — 1. Where is your nose? 
Your eyes? Your mouth? 

One of the best signs of awakening intelligence in young 
children is the comprehension of spoken words. We test 
this by asking these questions, which can be answered by 
a gesture. 



268 PHYSICAL DEFECTS 

2. Repetition of Sentences of Six Syllables. 
It rains. I am hungry. (6 syllables) . 

Experiment proves that it is easier for a child to repeat 
words than to speak a word of his own. If a child does not 
respond one may try him with two syllables ("mama") 
then four, etc. 

A child of three repeats six syllables but not ten. There 
must not be a single error. 

3. Repetition of Figures. ''6-4" 

A child of three can repeat two figures. Figures require 
closer attention than words because they mean nothing to 
him. Pronounce the figures distinctly, one-half second 
apart and without emphasis on any one figure. 

4. Describing Pictures. 

A picture is shown to the -child with the question. " What 
do you seef" The pictures must be chosen with some care. 
Each one must represent some people and a situation. Binet 
uses three pictures. The first is a man and a boy drawing 
a cart loaded with furniture. The second, a woman and an 
old man sitting on a bench in a park in winter. The third 
a man in prison looking out of the window; a couch, chair, 
and tables. 

A child of three names the things — enumerates. He 
does not describe any actions in the pictures. 

5. Name of the Family. 

All children of three know their first name. They some- 
times know the family name but not always. 

Children of Four years. — 1. Sex of Child. Are you a 
little boy or a little girlf 

If testing a girl, give the question in this form. Are you 
a girl or a boyf 

Children of three do not know. Children of four 
always do. 



MENTALITY 269 

2. Naming Familiar Objects. 

One takes from his pocket a key, a knife, and a penny. 

The answers should indicate that the child knows what 
each is. This is a more difficult use of language than naming 
objects in the picture because there the child chose his own 
object to name; here we say, "What is that thing f" 

3. Repetition of Three Figures. "7-2-9." 

4. Comparison of Two Lines. "Which is the longer 
liner 

Draw two parallel lines three centimeters apart, the one 
5 centimeters and the other 6. Hesitation is failure. 

Children of Five Years. — 1. Comparison of Two Weights. 
" Which is the heavier f" 

Use weighted blocks of wood of equal size and appearance. 

Compare 3 grams with 12 grams and 6 grams with 15 
grams. Note the curious and interesting errors that are 
made. 

2. Copying a Square. 

Draw a square of 3 or 4 centimeters. Have child copy 
it with ink^ — not pencil. Pen makes it harder. It is satis- 
factory if one can recognize the square. 

3. Repeats Sentence of 10 Syllables. 

Use this: His name is John. He is a very good boy. 

4. Counting Four Pennies. 

Place four pennies in a row. Insist that child count 
them with his finger. 

At three years a child does not know how to count four; 
at four half succeed; at five all succeed. 

5. Game of Patience with Two Pieces. 

Cut a visiting card diagonally. Place a whole card on the 
table. Nearer the child place the two pieces with the two 
hypotenuses away from each other. Ask the child to make 
a figure like the uncut card. One child in twelve fails. 



270 PHYSICAL DEFECTS 

Be careful (1) that child does not fail because he is too 
indolent to reach out and try; (2) that one of the pieces does 
not get turned over — because then it is impossible; (3) 
that you do not show by a look whether the child is right 
or wrong. 

Children of Six Years. — 1. Distinction between Moen- 
ING AND Afternoon. "Is this morning or is it afternoon?" 
It should be remembered that a certain type of child will 
always answer the last of two alternatives. Therefore if 
the time is afternoon, it is w^ell to put the question, "Is 
this afternoon or morning f Not before six do children 
know this. 

2. Definition of Known Objects. " What is a fork? 
a table? a chairf a horsef a mamaf 

There are three kinds of response. (1) Silence, simple 
repetition, or gesture, e. g., "A fork is a fork," or pointing 
say, " That is a chair." (2) Definition in terms of use, 
"A fork is to eat with." (3) Definitions better than by use. 
This includes all answers that describe the thing or even 
begin with "it is a thing" — "it is an animal," etc., all of 
which expressions are not so child-like as the simple "use" 
definitions. In deciding which type of answer we shall 
credit to the child, we accept three out of five. 

At four years half the children define by "use;" it increases 
a little at five and at six practically all define this way. 
Not before nine do the majority give the definitions that 
are "better than by use." 

3. Execution of Three Simultaneous Commissions. 
"Do you see this key? Put it on that chair. Then shut the 
door. After that bring me the box that is on the chair. Remem- 
ber, first the key on the chair, then close the door, then bring 
in the box. Do you understand? Well, then, go ahead." 
Such are the directions. They must all be done without 



MENTALITY 271 

further help, hint, or suggestion. At four years almost none 
can do this; at five about half; at six all, or nearly all, 
succeed. 

4. Right Hand, Left Eae. 

One says to child "Show me your right hand,'" and when 
that is done, " Show me your left ear." There are, in the main, 
three kinds of response. (1) Does not know right and left. 
Shows right hand because of natural tendency. Shows right 
ear also. (2) Knows but is not sure. Shows right hand, 
then right ear, but corrects himself at once. (3) Knows 
and without hesitation touches right hand and left ear. 
(2) and (3) are considered satisfactory. If child touches 
one hand with the other in such a way that one cannot 
tell which hand he means, ask him to hold his right hand up 
high. Be very careful in this test to give no hint by look or 
word. At four years nc child points to left ear; at five half 
of the children make a mistake; at six all succeed. 

5. Esthetic Compaeison. 
"Which is the prettier f" 

Binet uses six heads of women in three pairs, the one 
pretty and the other ugly or even deformed, Fig. 69. Care 
is taken that the pretty one is now at the left and now at 
the right. At six all choose correctly; at five about half. 

Children of Seven Years. — 1 . Counting Thirteen Pennies. 

Pennies must be placed in a row and counted with the 
finger. Finger must touch the piece at the same time that 
the child names the number. No piece must be counted 
twice and none omitted. The number thirteen must be 
given exact. At six years two-thirds fail; at seven they 
make no errors. 

2. Description of Pictures. 

Same picture as used in age three. Child now describes 
things instead of simply enumerating. 



Fig. 69 





>\^.^^ 




Binet test, age six years. No. 5. 



Fig. 70 





18 



Binet test, age seven years. No. 3. 



274 PHYSICAL DEFECTS 

3. Unfinished Pictuhes. 

One shows four sketches of such as Fig. 70. Ask the child 
''What is lacking in that piduref Child must answer 
three out of four correctly. At five years none are correct; 
at six errors number two-thirds; at seven the great majority 
are accurate. 

4. Copying a Diamond. 

Draw a rhombus about the size of the square used for 
age five. Have child copy this with pen. The result is 
satisfactory if it would be recognized as intended for a 
diamond-shaped figure. 

5. Name Four Colors. Use red, blue, green, and yellow 
papers, in pieces about 1x3 inches. Touching each color 
with the finger ask, ''What is that colorf It will be seen 
this is a test of color names not of discrimination. It 
should be done in 6 seconds. 

Children of Eight Years.— 1. Compare Two Things from 
Memory. "What is the difference between a butterfly and a 
fly? " Wood and glassf " Paper and pasteboard {or cloth) ?" 
The question may be differently put so as to make it intel- 
ligible as possible, e. g., " Why are they not alikef etc. 

Two at least out of the three pairs should be answered 
correctly. If it takes more than two minutes it is a 

failure. 

At six a third of the children do this test; at seven nearly 

all; at eight all. 

2. Count Backward from 20 to 1. 

This should be done within 20 seconds, and only one 
mistake allowed of omission or transposition. 

3. The Days of the Week. These must be given in 
order without omission within ten seconds. Most persons 
would expect that this could be done before age nine, but it 
cannot. 



MENTALITY 275 

4. Count Nine "Sous" (3 Singles and 3 Doubles). 
(Our two-cent piece is now so rare that we use 1-cent and 

2-cent postage stamps.) Arrange in order, 1, 1, 1, 2, 2, 2, 
" How much are they worth? ( How much money to buy 
themf) "Count.'" It should be done within ten seconds 
without any error. There are three ways of counting. One 
child says 1, 2, 3, 5, 1, 9. Another says 1, 2, 3, 4-5, 6-7, 8-9. 
The third says, 1, 2, 3, 4, 5, 6, which is of course wrong, 
A large majority do this test at seven years. But all do it 
at eight. 

5. Repetition of Five Figures. "4-7-3-9-5." Same 
method of procedure as given above, age three. Only three- 
fourths of the children succeed. 

Children of Nine Years. — 1. Make Change — 9 Cents out 
OF 25. 

Play store, using real money. If child's cash consists 
of 25 pennies, 5 nickels, and 2 dimes, interesting degrees 
of intelligence will be discovered by noticing the coins he 
uses in making change. Child is storekeeper. One buys 
something that costs 9 cents. Child must actually give 
16 cents as well as say it. 

At seven no one can do this test; at eight a good third 
succeed; at nine all do it. See Revision. 

2. Definition Better than by "Use." 

This was explained under age six. At ages seven and 
eight, half the children give definitions of this kind. At 
nine they all do. 

3. Name the Day of the Week, the Month, the Day 
OF THE Month and the Year. 

The test is passed even if the day of the month is as much 
as three days wrong. Children least often know the year. 

4. The Months of the Year. 

Recited in order within fifteen seconds. Allow one omis- 
sion or transposition. 



276 



PHYSICAL DEFECTS 



5. Arrangement of Weights. 

Use five wooden cubes of same size and appearance, but 
loaded so as to weigh 6, 9, 12, 15, 18 grams. (Metal pill 
boxes may be used.) Place the five boxes on table in 
front of child and explain that they do not all weigh alike 
and he is to lift them one at a time and put them in order 
from the lightest to the heaviest. (The initial of each 
weight written on the bottom of each box makes it easy 
to see it they are right.) Record the exact order in 
which the child has placed them. Three trials are made. 
Two must be absolutely correct. The whole operation 
must not take over three minutes. 

Children of Ten Years. — 1. Naming Nine Pieces of 
Money. One may use cent, nickel, dime, quarter, half 
dollar, dollar, two dollars, five dollars, and ten dollars. 

Pieces should be on table in a row but not in regular order 
of value. Point with finger, and name as he points. 

2. Draw Design from Memory. 




3. Repeats Six Figures. See Revision. 

4. Questions of Comprehension. First Series. 
What ought one to do: 

1. When one has missed the train? 

2. When one has been struck by a playmate who did not 
do it purposely? 

3. When one has broken something that does not belong 
to one? 

At seven and eight half respond correctly; at nine three- 
fourths; at ten all. If two questions out of three are answered 
correctly the test is passed. 



MENTALITY 277 

Second Series. 
What ought one" to do. 

1. When he is detained so that he will be late for school? 

2. What ought one to do before taking part in an impor- 
tant affair? 

3. Why does one excuse a wrong act committed in anger 
more easily than a wrong act committed without anger? 

4. What should one do when asked his opinion of some 
one whom he knows only a little? 

5. Why ought one to judge a person more by his acts 
than by his words? 

Allow at least twenty seconds to each question. Three 
of the five must be answered correctly. At seven and eight 
no one responds to a majority of this second series; at ten 
half are successful; it is therefore a transition between ten 
and eleven years. 

5. Using Three Words in a Sentence. 

Binet uses the words Paris, fortune, river. We should say 
Philadelphia, money, river. This is the first time in these 
tests that we have required the child to "invent" his own 
expression. There are three forms of answers. (1) Three 
separate sentences. (2) Two ideas united by a conjunction. 
(3) A single idea involving the three words. Only the last 
two are satisfactory for the test. We allow one minute. 
At eight no one succeeds. At nine one-third, and at ten 
one-half get it right. 

In this test may be seen a distinction between intelligence 
and judgment. Some children give a complete sentence 
with three words, but they do not make sense. 

Children of Eleven Years. — 1. Criticism of Sentences. 

These are sentences that contain some absurdity or 
ridiculous expression. Binet explains that formerly he used 
sentences like "Is snow red or black f" but he found that 



278 PHYSICAL DEFECTS 

many bright children fell into the trap and others through 
confidence in the questioner failed to look for an absurdity. 
Therefore he has changed the plan and now says to the 
child, "I am going to give you some sentences in which there 
is nonsense. You listen carefully and see if you can tell me 
where the nonsense is." Then he reads the sentence very 
slowly. 
These are the sentences: 

1. An unfortunate cyclist has had his head broken and is 
dead from the fall; they have taken him to the hospital and they 
do not think that he will recover. 

2. I have three brothers, Paul, Ernest, and myself. 

3. The police found yesterday the body of a young girl cut 
into eighteen pieces. They believe that she killed herself. 

4. Yesterday there was an accident on the railroad. But 
it was not serious; the number of deaths is only 48. 

5. Someone said, "If in a moment of despair I should 
commit suicide, I should not choose Friday, because Friday 
is an unlucky day and it would bring me ill luck." 

The test should last about two minutes. Three at least 
of the questions should receive good answers. At nine years 
hardly any child gets them; at ten scarcely a fourth; at 
eleven a half. 

2. Three Words in a Sentence. (Given under age ten.) 
At eleven all succeed. 

3. Sixty Words in Three Minutes. 

" Say as many words as you can in three minutes; as table, 
board, beard, shirt, carriage." We tell him that some 
children have named 200 words. 

This test gives a splendid opportinity to appreciate the 
intelligence of a child. At least 60 words must be given. 

4. Rhymes. 

Explain what is meant by one word rhyming with another. 



MENTALITY 279 

Illustrate. Then ask for as many words as the child can 
think of, that rhyme with a given word, e. g., day or 
spring or mill. 

One minute is allowed. Three rhymes with one word 
should be found in the given time. 

5. Words to Put in Order. "Make a sentence out of 
these words." 

Hour — for — we — early — at — park — an — started — the. 
To — asked — paper — my — have — teacher — correct — the 
—I. 

A — defends — dog — good— his — bravely — master. 

Place the printed words before the child. He gives the 
sentence orally. 

Time limit is one minute for each sentence. At least two 
must be given correctly. 

Children of Twelve Years. — 1. Repetition of Seven 
Figures. 2,9,4,6,3,7,5. 1,6,9,5,8,4,7. 9,2,8,5,1,6,4. 

Tell the child there will be seven figures. Give three 
trials. One success is sufficient. 

2. Abstract Definitions. 

"What is Charity? Justice? Goodness?" 

Two good definitions must be given. It is often somewhat 
difiicult to decide if the definition is passable. If it contains 
the essential idea it must be accepted however badly it is 
expressed. At ten years a third succeed; at eleven they are 
generally successful. 

3. Repetition of a Sentence of 26 Syllables. See 
Revision for new Sentence. 

This should be done without error. 

" Children, it is necessary to work very hard for a living. 
You must go every morning to your school." — 24 syllables. 



280 PHYSICAL DEFECTS 

" The other day I saw in the street a pretty young dog. 
Little Maurice has got spots on his new apron." — 26 syllables. 

"Ernest is praised very often for his good conduct. I 
bought at the store a beautiful doll for my little sister." — 28 
syllables. 

" There occurred on that night a frightfid tempest with light- 
ning. My comrade has taken cold. He has a fever and coughs 
very much." — 30 syllables. 

4. Resists Suggestions. 

5. Problem of Various Facts. (What is it?) 

" A person who was walking in the forest at Fontainebleau 
suddenly stopped much frightened and hastened to the nearest 
police and reported that he had seen hanging from the limb 
of a tree a " (after a pause) "what?" 

"My neighbor has been having strange visitors. He has 
received one after the other a physician, a lawyer, and a clergy- 
man. What has happened at the house of my neighbor?" 

Both questions should be answered correctly. 

The answer to the first is "a dead man." Some object 
to this story as too gruesome. Others say that children are 
not so sensitive to such things as we think. Aside from that 
question it would seem that the picture is hardly familiar 
enough in America to make the answer certain. A 'substi- 
tute had better be found. 

Children of Fifteen Years. See Revision. Adult. — 1. 
Cutting Out. 

Get the child's attention and let him see you fold a sheet 
of paper in four. Then with the scissors cut a small triangle 
from one edge — the edge which does not open. Ask him 
to draw a picture of the paper as it will look when unfolded. 
Do not unfold or allow another sheet to be folded. It is a 
difiicult test. If a child does it the first time always ask 
him if he has seen it before. 



MENTALITY 281 

2. The Reversed Triangle. 

Cut a visiting card along the diagonal. Ask child to 
describe the resulting shape if one of the triangles was 
turned about and placed so that its short leg was on the 
other hypotenuse and its right angle at the smaller of the 
two acute angles. 

3. Differences. 

Ask the difference between 
Pleasure and honor. 
Evolution and revolution. 
Event and advent. 
Poverty and misery. 
Pride and 'pretention. 

4. Difference between President of a Republic 
AND A King. 

5. Gives Sense of a Selection Read to Him, See 
Revision for 4 and 5. 

Such are the tests. In practice the examination should 
be conducted in a quiet place, the child being taken alone 
and as free from distractions as possible. The examination 
should not and need not last long enough to fatigue the 
child. Begin with the tests corresponding to the age of the 
child or below according as the child seems average or dull. 

It is very desirable, when feasible, to have an assistant 
who records verbatim everj^thing that the child says as well 
as makes notes on what he does during the examination. 
When this is impossible the examiner must keep his own 
notes, but care should be had that they be made as rapidly 
as possible, consistent with accuracy, so as not to keep 
the child waiting. This spoils the game. As said above, 
constantly encourage the child; continually tell him he is 
doing splendidly. 

While examining the child forget all your preconceived 



282 PHYSICAL DEFECTS 

ideas. Regard him as an unknown quantity, an x which 
is to be determined. 

Finally, these tests of Binet and Simon, while they seem 
to have been worked out with great care and are the result 
of large clinical experience so that they seem to be almost 
mathematically exact, yet they must be used with judgment 
and intelligence. 

I believe they are the most valuable contribution yet 
made and in the hands of the reasonably intelligent teacher 
or parent will be found of great help in "measuring" the 
intelligence of the child and determining whether he is in 
need of special treatment. When such need is indicated 
even to a possibility he should be taken to an expert whose 
large experience with such children enables him to confirm 
the suspicion or to show why it was unfounded. 

The reader who is at home with French should read the 
original article of Binet and Simon, L'Amie Psychologique, 
1908, part of which we have here condensed. The rest of 
the article containing discussions and suggestions we hope 
to resume at another time. 

The Revision. — In the following list we give an arrange- 
ment which embodies our experience while following Binet's 
new order as closely as we can. 

We believe that for American children, at least, this 
scale is about as accurate as it can be made. 

Attention should perhaps be called to the fact that this 
revision does not at all imply that the results obtained with 
the old one were wrong. The method of counting devised 
by Binet was so accurate that it enabled the examiner to 
do the child justice even if a few questions were misplaced. 
The new scale will simply be more convenient because it 
will obviate straggling; that is, where a child, for example, 
stops at seven years, but gets enough credits to make him 



MENTALITY 



283 



eight, some of these credits coming from nine and some from 
ten. The tendency under the new scale will be to answer 
the eight-year questions and stop there, doing none in nine 
or ten. Undoubtedly this will not always be the case, but 
it will occur oftener than with the old scale. 

The following are the questions as we now use them: 



No Change 



III 

1 Points to nose, eyes, mouth. 

2 Repeats "It rains. I am hungry. 

3 Repeats 7, 2. 

4 Sees in Picture 1. 

2. 
3. 
4. 
5. 



5 Knows name. 



IV 



1 Knows sex, boy or girl (girl or boy). 

2 Recognizes key, knife, penny. 

3 Repeats 7, 4, 8. 

4 Compares lines. 



Binet 


Binet 




new. 


-old. 




1 


1 


1 


2 


2 


2 


3 


(new) 


3 


4 


4 


4 


5 


3 


5 


1 


7 


1 


2 


4 


2 


VII 3 


5 


3 


VIII 


1 


4 


5 


3 


5 


VI 4 


7 


1 


2 


6 


2 


VIII 3 


1 


3 


VIS 


4 


4 


5 


VIII 3 


5 



V 

Compares 3 and 12 grams; 6 and 15 . 32- 2 

Copies square 23-11 

Repeats: His name is John. He is a very 

good boy new 

Counts four pennies 30- 4 

"Patience" 20-12 

VI 

Morning or afternoon . . . . . 30-12 

Defines fork, table, chair, horse, mama 35- 6 

Puts key on chair, brings box, shuts door 25- 7 

Shows right hand, left ear .... 35- 8 

Chooses prettier 31-9 

VII 

Counts 13 pennies 94- 5 

Describes pictures 83-25 

Sees picture lacks eyes, etc 87- 9 

Can copy diamond 95- 8 

Names colors, red, blue, green, yellow . 97- 5 



284 



PHYSICAL DEFECTS 



2 


4 


2 


omitted 


1X2 


3 


VII 4 


2 


4 


5 


VII 5 


5 


1 


3 


1 


2 


4 


2 


VIII 4 


1 


3 


4 


XI 


4 


XI 


6 


5 



1X3 



new 
new 



VIII 

Compares two objects from memory, but- 
terfly, fly: wood, glass, paper, cloth . 87- 2 
Counts backward 20 to 1 .... 90- 1 

Repeats days of week 85- 4 

Counts stamps 111222 79-14 

Repeats 5 figures 36- 7 



IX 

Makes change, 20c, 4c 
Definitions better than use 
Knows date .... 
Repeats months in order 
Arranges 5 weights 



33-23 

45-27 
48- 7 
48- 6 
44-11 



X 



1 Knows money Ic, 5c, 10c, 25c, 50c, $1, $2, 

$5, $10 104- 5 

3 Repeats six figures: 854726, 274681, 941- 

738 . new 

2 Draw design from memory (show 10 

sec.) new 

4 Comprehends easy questions . . . 98- 8 

5 Uses 3 words in two sentences . . . 92-17 



X3 



XII 2 


2 


2 


XII 3 


3 


3 


XV 2 


2 


4 


XII 5 


5 


5 


XVI 


1 


1 


XII 4 


X4 


2 




3 revised 


3 


1 


new 


4 


XV 5 


4 


5 



1 


XIII 1 


1 


2 


XIII 2 


2 


3 


XIII 3 


3 


4 


new 


4 



XI 

Sees absurdity; painter, brothers, locked 

in room, raUroad accident, suicide . 48— 4 

Uses 3 words in a single sentence . . 39-14 

Gives 60 words in three minutes . . 35- 3 

Gives three rhymes 45- 5 

Puts dissected sentences together . . 35- 9 



XII 



Repeats 7 figures 

Defines charity, justice, goodness 
Repeats sentence of 26 syllables 
Resists suggestion .... 
Problems: (a) Hanging from limb 
(b) Neighbors, visitors 

XV 



37- 7 
5- 
15-21 
new 

40- 3 



1 Interprets picture. 

2 Change hands of clock. 

3 Code. 

4 Opposition. 

Adult 
Cutting paper. 
Reversed triangle. 
Gives differences of abstract words. 
Difference between president of a republic and 

a king. 
Gives sense of a selection read to him. 



MENTALITY 285 

All questions under any age must be answered to pass 
that age — instead of all but one as in the old scale. 

Explanation of the Revised Binet Scale. — ^The names 
of the tests are abbreviated, but will be understood by 
reference to the old list. The new questions are explained 
below. 

The number of the question, as it w^as in the old list, is 
given immediately before the present number. The first 
number in the line shows the place of the question in Binet's 
revised scale, e. g., VIII 3 (repeat days of week), was IX 2 
in old scale, and Binet omits it entirely from his new scale. 
Following each question we give the successes (first figures) 
and failures (last figures) on the question by normal children, 
as obtained from our examination of two thousand normal 
children. (See Pedagogical Seminary, June, 1911.) For 
example, in V 1, 32 succeeded and 2 failed. 

IX. 1. Our old form was too hard. We propose now, 
20c. — 4c., and give the child two dimes. This is Binet's 
form, but he has a 20-cent piece, which we lack. However, 
two dimes will probably do as well. 

IX. 2. At Vineland we have been a little too strict on 
this question. We now propose to accept any definition 
that is more than simply "use," e. g., chair has four legs, 
table is made of wood, etc. 

X. 2. Use this design. Expose 10 seconds. Have child 
draw his design on back of record sheet. (This should be 
considered satisfactory as one who did not know just what 
the design was would recognize it. No account is taken of 
proportions or crookedness of lines or perspective. It is 
well to remind the child before beginning that he is to draw 
both parts.) "Tests attention, visual memory, and a little 
analysis." 



286 PHYSICAL DEFECTS 

XI. 4. There should be three rhymes with each of three 
words. The fourth word is intended to be used as an 
illustration, the examiner giving rhymes for that. 

XI. 5. In the dissected sentence, the second one which 
has the word "have" in it, proves to be the most difficult. 
However, since the test is passed if two are correct, the 
other two will give the child a fair chance. 

XII. 3. Old sentence too hard. Use the following: I 
saw in the street a pretty little dog. He had curly brown 
hair, short legs, and a long tail. 

The Following Questions Were Not in the Old 
List: 

XII. 4. Binet's description of this test is as follows: 

Prepare a little booklet of six pages. On first page draw 
in ink two lines horizontal; the one to the left 2 inches (4cm.) 
long, the one to the right 2| inches. On second page, left 
line is 2|, right, 3 inches. Third page, left line 3 and right 
one 3| inches. On three remaining pages all lines are 3^ 
inches long. The lines on each page are in same straight 
line and separated by ^ inch. 

The idea of the test is this: Child having said the right- 
hand one is longer for three times, will he continue even 
when he comes to those that are alike or will he "resist 
the suggestion" and say they are alike? 

Care must be exercised in asking the question. For the 
first two pages ask, "Which is the longer line?" but for the 
others say merely, "And there?" 

XV. 1. Use same pictures as in III 4 and VII 2. The 
test is credited in XV if subject "interprets^' the feeling of 
the picture — usually expressed by some word of sympathy, 
fear, sorrow, joy, or other feeling. 

XV. 2. Interchange the hands of a clock for (1) the hour 
6.20 and (2) 2.56. (Child must not see a watch or^clock. 



■ MENTALITY 287 

It is a test of imaging power.) We say to the child, " Can 
you think how the clock looks when it is twenty minutes 
past six (four minutes before three) ? Well, now tell me what 
time the clock would show if I changed the hands, putting 
the long hand where the short hand is and short hand 
where long hand is?" 

XV. 3. This test was suggested by Dr. William Healy, 
of Chicago. It was used by the Southern army in the Civil 
War. 

The diagrams shown below are to be constructed while 
the child gives close attention. He notes the arrangement 
of the letters, in alphabetical order vertically in first and 
second, and counter-clockwise in the third and fourth 
diagram. Two and four differ from one and three in having 
a dot in each section. Once knowing the scheme, the letters 
may be left out and a cipher dispatch written by using for 
each letter the part of the diagram in which the letter is 
placed in the key. For example "war" would be written: 

V J r 

Having made it perfectly clear, remove the key and have 
child write on back of record sheet, "Caught a spy," in 
this code. In crediting allow one error. Every wrong or 
incomplete symbol is an error. 

It should be remembered that this is to be very carefully 
explained to the child. He is allowed to look at the dia- 
grams, and it should be illustrated, but after the test 
begins the child should not draw the diagrams for him- 
self. He should work out the code simply from memor- 
izing. He may count up on his fingers and find out where 
the letter would be, but he must not write down the 
diagram. 



288 



PHYSICAL DEFECTS 



A 


D 


G 


B 


E 


H 


C 


F 


I 



J 

• 


M 

• 


P 

• 


K' 


N 

• 


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XV. 4. Ask child to write the opposites of the following 
words: 1, good; 2, outside, 3, quick; 4, tall; 5, big; 6, loud; 
7, white; 8, light; 9, happy; 10, false; 11, like; 12, rich; 
13, sick; 14, glad; 15, thin; 16, empty; 17, war; 18, many; 
19, above; 20, friend. 

Illustrate. One may say, "Tell me just exactly what this 
word does not mean," or "If a child is not good, what is he?" 
But this latter should not be repeated with each word, 
only once or twice as illustrations; then the child should 
give the opposites after that. If he is unable to do this, his 
very lack of comprehension is sufficient evidence that he 
cannot pass the test. 

Besides the obvious answers, the following are accepted 
as right or half right: 

2, in or indoors (half); 3, lazy or slowly (half); 4, little 
or low (half); 5, short (half); 6, soft or low (right), whisper 
(half); 9, sorry or sorrow (half); 10, right or truth (half); 
11, dislike, unlike or hate (right); 13, healthy (right); 14, 
mad (right); 15, broad (half); 16, filled (right); 18, none 
(right); 19, under (right). 

It is best to have the words printed on a slip of paper 
in vertical column, with space for child to write the " oppo- 
site" at the right. 

The equivalent of 17 correct answers must be 
given. 



MENTALITY 289 

"Adult."^ — ^Adult 4. Say to the subject: "There are 
three differences between the President of a Republic and a 
King. What are they?" 

The answer should contain the three ideas, Royalty is 
(1) hereditary, (2) lasts for life, and (3) the monarch has 
extended powers. The President is (1) elected, (2) for a 
definite time, and (3) his powers are usually less extensive 
than those of a king. 

Adult 5. Explain to the subject that you are about to 
read a selection to him, and that then you will ask him to 
tell you the substance of what you have read. He should 
give close attention. 

Read slowly, in a clear voice and with expression, the 
following : 

"One hears very different judgments on the value of life. 
Some say it is good, others say it is bad. It would be more 
correct to say that it is mediocre; because on the one hand 
it brings us less happiness than we want, while on the other 
hand the misfortunes it brings are less than others wish 
for us. It is the mediocrity of life that makes it endur- 
able; or, still more, that keeps it from being positively 
unjust." 

It is correct if the subject gives the central thought in 
his own words, e. g., "Life is neither good nor bad, but 
mediocre, because it is inferior to what we wish and not as 
bad as others wish for us." 

The tests for "XV" and "adult" are new, and we shall 
be glad to receive any comments or the results of any use 
of them. We have concluded that adult 1 and 2 test special 
traits rather than universal, e. g.,we found in a mixed group 
of educators and scientists, six out of twenty succeeded 

1 Binet explains that the word adult is not to be understood literally. It 
can only mean "over fifteen years." 
19 



290 PHYSICAL DEFECTS 

with No. 1. In another group, psychologists, twelve out 
of eighteen succeeded. 

The great need just now is to get suitable test up to age 
twenty. Perhaps there are no better ones than the tests 
of experience, and we may some day conclude that the boy 
or girl who has had an opportunity, and has not conformed 
to the canons of civilized society, is fundamentally defective 
in the qualities necessary to a useful citizen. 

Alternative Questions. — It sometimes happens that one 
wishes to test a child a second time, a few weeks after an 
earlier test. There is some fear that he may have remembered 
the questions or have been coached in his answers. In such 
cases an alternative set of questions is convenient. 

Many of the questions need no substitute, e. g., one 
cannot " learn' ^ to arrange the five weights. If he cannot 
do it no amount of coaching will help him. 

In other cases possible variants are so obvious that we 
leave them to the user. However, it is not always as easy 
as it looks, and he must be very careful or he will introduce 
changes seemingly small, yet which either change the diffi- 
culty radically or change the test utterly. 

The following suggestions may prove helpful: 

V. 3. Repeat "Little Mary likes to play with her 

dolls." 
VI. 2. Define spoon, bed, drum, cow, father. 
VI. 4. Show left hand, right ear. 
VIII. 1. Difference between horse and cow, stone and 

egg, grass and tree. 
VIII. 3. Name days of week backward. Allow more 
time. 
IX. 4. Give months backward. Allow more time. 
X. 2. Use design upside down or turned at 90 
degrees. 



MENTALITY 291 

X. 4. Comprehension. Use any of the following: 

1. What ought one to do when he is 

sleepy ? 

2. When he is cold? 

3. When he sees that it is raining just as 

he is about to go for a walk? 

4. When one is tired and a long way from 

home? 

5. Why is it necessary to save one's money 

and not spend it all? 

6. What ought one to do when he has 

received punishment that he did 
not deserve? 

7. What should one do to get a watch that 

he wants at store? 

8. What should one do when some one has 

offended him and comes and asks 
pardon ? 

9. What happens when two persons discuss 

a question without understanding 
the words? 

10. What should you do when a person 

always contradicts you, no matter 
what you say? 

11. Why is it better to persevere in what 

one has begun than to give it up 
to try something new? 

12. Why should one not taunt a person of 

the service one has done him? 

13. What ought one to do who has done an 

irreparable wrong? 
X. 5. Use the words snow, play, sled. 
XI. 1. Use any of the following: 



292 PHYSICAL DEFECTS 

XI. 1. Do you see any absurdity in the following? 

1. I like the end slices of bread. I gave the 

girl a whole loaf of bread and told 
her to bring me the two end slices. 
I afterward found that she had 
sliced the entire loaf. I asked her 
why she did this. She said, "How 
could I get the second end piece 
unless I did?" 

2. A man asked a boy where Mr. Smith 

lived, he said, "The first house you 
come to is a barn and the next is a 
haystack. The next is Mr. Smith's." 

3. A man said to his friend, "May you live 

to eat the chickens that scratch sand 
on your grave." 

4. A man came to see Prof. Johnstone; 

Prof. Johnstone was not at home. 
I asked him his name. He said, 
"Oh, it is not necessary to leave my 
name; Prof. Johnstone knows me." 

5. A gentleman fell from his carriage and 

broke his neck, but received no 
further damage. 

6. I received a letter from a friend in which 

he said, "If you don't get this letter 
just let me know and I'll write again." 

7. I read in a paper that they fired two 

shots at a man. The first shot 
killed him, but the second didn't. 

8. The judge said to the prisoner, "You 

are to be hanged, and I hope it will 
be a warning to you." 



MENTALITY 293 

XI. 4. Rhymes use man, toy, cold. 
XI. 5. DAY — IT— WE— PICNIC — THE— OUR— 
RAINED— HAD. 
IF — ASKED— BALL— MY— HAVE— WE— 

MOTHER— PLAY— I— MAY. 
A — MAKES— BOY— GOOD— HIS— HAPPY 
—MOTHER. 
XII. 2. Defines truth, mercy, pity. 
XII. 3. Repeat, " Mary is often praised for her very nice, 
neat work. She is always a good little girl, and likes to sew." 
XII. 5. (a) A man walking in the woods began to be 
worried. He looked to right and left. He walked back and 
forth. He climbed a tail tree. 

"What was the matter?" The answer is, of course, he 
lost his way. 

(6) I saw a crowd going along the street. They were all 
dressed up and each had a basket or a bundle. 

"Where were they going?" Answer, a picnic or excursion. 
XV. 3. The code may be easily changed by changing 
the arrangement of the letters from vertical to horizontal, 
counter-clockwise to clockwise, etc. 

XV. 4. Other lists may be made up. 
Some may desire to use the reading test, although Binet 
omits it from the new list. The following selection is a 
little easier than the old one and we suggest it as a nine- 
year test. In our Vineland study the reading was passed 
at eight years in the ratio of forty-nine — thirty-three and 
at nine years in the ratio of forty-eight — seven. 

NEW YORK, JUNE 5. 

A big flood at Cape May swept away five boats full of fish. 
A little boy, the son of a fisherman, was carried out to sea. 

While trying to save him a man in a row boat was washed 
overboard and nearly drowned. The child was saved. 



294 PHYSICAL DEFECTS 

Name Born Admitted 

III 

1 Points to nose, eyes, mouth. 

2 Repeats "It rains. I am hungry." 

3 Repeats 7 2. 

4 Sees in Picture 1. 4. 
(Enumerates) 2. 5. 

3. 6. 

5 Knows name. 

IV 

1 Knows sex, boy or girl, (girl or boy). 

2 Recognizes key, knife, penny. 

3 Repeats 7, 4, 8. 

4 Compares lines. 

V 

1 Compares 3 and 12 grams. 6 and 15 grams. 

2 Copies square. (Draw on back of this sheet.) 

3 Repeats, "His name is John. He is a very good boy." 

4 Counts four pennies. 

5 "Patience." 

VI 

1 Morning or afternoon, (afternoon or morning) 

2 Defines fork horse 

table mama 

chair 

3 Puts key on chair; shuts door; brings box. 

4 Shows R. Hand. L. Ear. 

5 Chooses prettier 1 and 2. 4 and 3. 5 and 6. 

VII 

1 Counts 13 pennies. 

2 Describes pictures. (Action.) (See III 4.) 

3 Sees picture lacks eyes, nose, mouth, arms. 

4 Copies diamond, (over) . 

5 Recognizes red, blue, green, yellow. (Time 6".) 

VIII 

1 Compares (Time 20".) 

Butterfly Wood Paper 

Fly Glass Cloth 

2 Counts backward 20 to 1. (Time 20".) 

3 Repeats days. M. T. W. T. F. S. S. (Time 10".) 

4 Counts stamps. 111222. (Time 10".) 

5 Repeats 4 7 3 9 5. 

IX 

1 Makes change 20c — 4c. 

2 Definitions (see VI 2). 

3 Knows date. 

4 Months. J. F. M. A. M. J. J. A. S. O. N. D. (Time 15".) 

5 Arranges weights. (2 correct) (1 min. each). 1. 2. 3. 

Record Blank 
For Revised Binet Tests 
Examined Mental Age 



MENTALITY 



295 



X 

1 Money Ic, 5c, 10c, 25c, 50c, $1, $2, $5, $10. 

2 Draws design from memory. (Show 10 seconds.) 

3 Repeats 8 5 4 7 2 6. 274681. 941738. (1 out of 3 correct) 

4 Comprehends. 

(2d series time 20"). 

(3 out of 5) 

a. (Late to school) 

b. (Important affair) 

c. (Forgive easier) 

d. (Asked opinion) 

e. (Actions vs. words) 
Philadelphia, Money, River. (Time l") 



(1st Series time 20") 
(2 out of 3) 

a. (Missed train) 

b. (Struck by playmate, etc.) 

c. (Broken something) 



5 Sentence: 



R. R. accident. 
Suicide. 



XI 

1 Sees absurdity. (3 out of 5) (Time 2') 

a. Unfortunate painter. 

b. Three brothers. 

c. Locked in room. 

2 Sentence: Philadelphia, Money, River. (See X 5.) 

3 Gives sixty words in three minutes. (Record on back of this sheet). 

4 Rhymes (time l' each) (3 rhymes with each word) (All correct) 

day mill 

spring 

5 Puts dissected sentences together. (Time l' each) (2 out of 3 correct) 
a. b. c. 



XII 

9 2 8 5 16 4. 



13 9 5 8 4 7. (1 out of 3 correct) 



Repeats 2 9 6 4 3 7 5. 
Defines Charity 

Justice 

Goodness 
Repeats, "I saw in the street a pretty little dog. 

hair, short legs, and a long tail." 
Resists suggestion (lines). 1. 2. 3. 4. 5. 6. 
Problems: (a) Hanging from limb. (6) Neighbor's visitors. 



He had curly brown 



XV 

1 Interprets picture. 

2 Changes clock hands, (a) Twenty minutes past six. (6) Four minutes 

of three. 

3 Code- COME QUICKLY. 

4 Opposites. (The equivalent of 17 out of 20) 

1 good 5 big 9 happy 13 sick 17 war 

2 outside 6 loud 10 false 14 glad 18 many 

3 quick 7 white 11 like 15 thin 19 above 



4 tall 



8 light 12 rich 



16 empty 20 friend 



Adult 
4 



1 Cutting paper. (Draw) 

2 Reversed triangle. (Draw) 

3 Gives differences of abstract words 



Differences between president 
of a republic and a king. 
5 Gives sense of a selection read. 

Department of Research 
Training School at Vineland, N. J. 



296 PHYSICAL DEFECTS 



TREATMENT OF THE MENTAL DEFECTIVE, 
SUBNORMAL, OR RETARDED CHILD. 

The true mental defective, or those in whom there are 
defects of brain with total or almost total lack of function 
of this organ are not subjects for training in public schools. 
They should be institutional cases where life and training 
is mapped out along scientific lines. 

In the case of the subnormal, dull, and retarded child 
a thorough investigation should be made for the possible 
underlying causes of the defect and the proper treatment 
instituted. Where any defect has been located, whether 
in the school system, the home, or the child, every effort 
must be made to correct these defects. 

First, place the school, its system, and its teachers in the 
best possible position to care for and train the child. Study 
the teacher and her methods, her health, and temperament. 
Find out why in certain branches the child excels and in 
others fails. Study some pedagogical method of increasing 
interest in dull subjects. Individual interest and encourage- 
ment by a teacher often leads a seemingly dull boy to a 
higher standard. His weak points should not be dwelt 
upon, but his good points encouraged. Human nature 
asserts itself chiefly in childhood, he is then most amenable 
to kindness. 

Home conditions when at fault can often be corrected by 
visits and friendly, tactful advice from the nurse, teacher, or 
social visitor. In cases of poverty call freely for aid from 
the various philanthropic organizations at your command. 
An interested enthusiastic person will always find a solution 
for the many faulty conditions that may be found at the 
homes. 



TREATMENT OF MENTAL DEFECTIVE CHILD 297 

Physical defects when found should always be corrected 
whether or not they seem to contribute to the mental dul- 
ness. It is not necessarily true that all children with physical 
defects are subnormal mentally, but certain defects, espe- 
cially of the eyes and ears, are sure to handicap a child in 
its progress. 

Dr. L. Wessels, ophthalmologist for the schools of Phila- 
delphia, submits the following interesting study of 5000 
school children examined under a mydriatic for defective 
vision. Using age and grade as a factor of mentality, he 
concludes that 75 per cent, of these children are backward. 

There are many interesting features connected with this 
table that are worthy of study. 

One thousand one hundred and seventy, or 23 per cent., 
were in the average grades, and only 281, or 5 per cent., 
were above the average grades. 

The majority of the children were below the fourth grade. 

Four thousand two hundred and ninety-seven, or over 
83 per cent., were below the fifth grade. 

Only 1909, or 37 per cent., were above the third grade. 

Only 849, or 16.5 per cent., were above the fourth grade. 
■ Only 297, or 5.75 per cent., were above the fifth grade. 

Only 92, or 1.78 per cent., were above the sixth grade. 

Only 33, or 0.64 per cent., were above the seventh grade. 

Note among other things in the table that the number 
of pupils suddenly drops around the age of fourteen, the 
legal age at which children are permitted to work. Out 
of 285 children fourteen years old, 273, or about 97 per cent., 
were backward; the majority were below the fifth grade. 

These figures seem to indicate that most of these children 
leave school before they reach the fourth grade, or that the 
children in the higher grades have better vision or have 
their defects corrected with glasses. 



298 



PHYSICAL DEFECTS 



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TREATMENT OF MENTAL DEFECTIVE CHILD 299 

This investigation teaches the importance of detecting 
and correcting defective vision in children in the lower 
grades, as the early correction of these defects enables the 
the child to reach a higher grade and insures a better educa- 
tion when he reaches the quitting age of fourteen. Further- 
more, if less children are left behind in the lower grades, it 
will help to eliminate the overcrowding that exists in these 
grades. 

Children's eyes should be examined before they enter 
school. If this is not possible, the medical inspector should 
devote most of his time to examining the eyes of children 
in the kindergartens and first grades, as the correction of 
many grave visual defects then will greatly promote the 
future progress and usefulness of the school child and future 
citizen. 

In backward children it is a great advantage to have the 
medical examinations of the eyes, ears, nose, and throat made 
by specialists in these branches of medicine In large cities 
special clinics for school children should be held in these 
specialties in connection with systems of medical inspection. 

Special Schools and Special Classes. — Special schools should 
be of two classes : 1. Parental for the instruction of incorrigible 
and truant children. 

2. Special schools for the instruction of the backward 
child not a mental defective, imbecile, or idiot. 

Parental schools, as the name implies, take the place of 
the parents and supply the home discipline which is lack- 
ing. Care must be exercised that the good accomplished 
in these schools is not counterbalanced by home conditions. 

Special schools are for the training of children as individ- 
uals and. not in large groups. The curriculum is made to suit 
the individual child and the classes are small enough to 
admit of the teacher giving personal instruction. Equip- 



300 PHYSICAL DEFECTS 

ment and courses of study are arranged to suit the capa- 
bilities and interest of the children, and the teaching is 
performed by specially trained teachers. 

Special classes should be instituted in all large schools 
to instruct the child who is not dull or backward, but 
requires extra time and individual instruction to bring him 
up to the standard of the other pupils of his class. This 
may include pupils who fail in one or two subjects. These 
classes also should be supervised by specially trained 
teachers. 

Specially qualified or trained teachers for special schools 
and classes: The applicants for these positions should be 
closely studied as to their temperament and disposition. 
Kindness, gentleness, and an excess of patience are required, 
and an excellent training for such a position may be obtained 
at one of the institutions for feeble-minded children. In 
the State of New Jersey, near Philadelphia, is the New Jersey 
Training School for Feeble-minded at Vineland. This is 
an ideal institution, giving a special summer course for those 
desiring to take up this line of work. In Philadelphia at 
the University of Pennsylvania there is also a summer 
course to train special teachers. 

The normal schools and schools of pedagogy in other 
large cities should also establish such courses and train 
teachers to fill these positions. Because of the additional 
qualifications and training required of teachers of special 
classes, they should receive a greater compensation than 
the ordinary teacher, thereby inducing teachers to qualify 
for these positions. 

Institutions for Feeble-minded and Backward Children. — 
The need of these institutions requires no argument, and 
that there are too few in existence is evident. These insti- 
tutions should not only care for the children intrusted to 



TREATMENT OF MENTAL DEFECTIVE CHILD 301 

them, but should utilize these cases for study and advance- 
ment of the subject. Teachers and others desiring training 
should be able to obtain it at moderate cost. The board 
of managers, resident, and visiting staff should consist of 
physicians trained in diseases of the nervous system and 
mentality as well as prominent psychologists and pedagogists. 

The following short description of the Training School 
at Vineland, New Jersey, will give some idea of a typical 
well-regulated institution. 

At Vineland, New Jersey, about one hour's ride from Phila- 
delphia, is an institution with over four hundred feeble- 
minded who are cared for, treated, and educated by the 
most modern methods known. With over two hundred and 
fifty acres of farm land there is ample opportunity to have 
fresh air and utilize some of the grounds for teaching 
gardening. 

Of no small importance is the use of this great amount 
of valuable material for a summer school for teachers of 
backward or mentally deficient children. Lectures during a 
period of six weeks are supplemented by study and observa- 
tion of the children in the class-rooms. Men prominent in 
the pedagogical and medical world take part in the lectures. 

There is a completely equipped laboratory at the institu- 
tion for the scientific study of the cases. 

Clinics and Laboratories.— Psychological clinics and labora- 
tories are of value in the study of causes and treatment 
of mental deficiency and backwardness. They should be 
established in every large University and College which 
offers courses in pedagogy, and could be established with 
advantage in connection with normal schools. Material 
can readily be obtained or referred from the public schools. 
The equipment should include modern apparatus for the 
physical and mental examination of applicants. 



302 PHYSICAL DEFECTS 

MEDICAL INSPECTIONS BY TEACHERS OR NURSES. 

While the ideal system and best results are obtained by 
trained physicians as school inspectors, it is not absolutely 
necessary for the conduct of such work. If lack of funds 
or other cause prevents the employment of physicians, 
the routine inspections may be made by nurses or teachers. 
They, however, should not endeavor to make an absolute 
diagnosis or prescribe treatment. In all towns there are 
to be found some public-spirited physicians who can be 
interested in the undertaking, and will volunteer to examine 
children sent to them, and even make an occasional visit 
to the school. In a community where no physician is 
employed one of these volunteers should be called on for 
cases requiring diagnosis and treatment. Many of the gross 
physical defects can be detected by the teacher. She can 
test vision and hearing according to the instructions given 
in the chapters of this book, and as a condensed guide the 
procedure may be conducted as follows: 

When examining the eyes, use the test card placed in 
proper lighting — 20 feet distant. If the child shows normal 
vision and still has headaches and other symptoms referable 
to eye-strain, insist on a thorough examination by a compe- 
tent ophthalmologist. 

In testing hearing use the whispered voice test. Stand 
the child about 20 feet distant away from an open door or 
window. With the child facing the wall so he may not 
watch the movement of the examiner's lips, and while one 
ear of the child is closed, whisper words for him to repeat. 

The nose and throat can be examined only by a physician. 
The teacher can label a child as a "mouth breather" or 
"nasal obstruction," and leave the diagnosis of adenoids 
or enlarged tonsils to the doctor. 



MEDICAL INSPECTIONS BY TEACHERS OR NURSES 303 

Skin lesions are, numerous and difficult for a layman to 
diagnosticate. By assuming this responsibility what may 
seem as only "pimples" or "eczema" or "stomach rash" 
may be measles, chickenpox, smallpox, or other contagion. 

Carious teeth or unhealthy condition of mouth are readily 
recognized and can be referred to a dentist. 

Marked orthopedic defects can also be recognized by the 
teacher. Diseases of the nervous system and systemic 
diseases can merely be suspected and expert opinion should 
be obtained. 

The prevention of epidemics of contagious diseases, one 
of the most important functions of medical inspection, can 
be well controlled by the teachers. 

Each morning before beginning the lessons have a class- 
room inspection. The teacher asks the class to rise at the 
right hand side of the desks; extend arms in front of body 
and hold heads erect. The teacher takes her position by a 
window with her back to the light, and the children pass in 
front of her in single file returning to their seats. This 
entire procedure for a class of thirty or forty should take 
a little over five minutes. 

With note paper and pencil she notes uncleanliness, any 
rash on face or hands, redness or watering of eyes, swelling 
on face or neck, neck bandaged (sore throat), scaling or 
peeling of hands, cough, running of nose, and discharge from 
ears. 

Exclude every child with a rash and fever; every child 
with any symptoms of a sore throat; every child who 
vomits in school, as scarlet fever often begins with it. 

An excluded child for a suspicious contagious disease 
should not be returned to its class until it presents a certifi- 
cate from a physician stating it is free from any contagious 
disease. 



304 



PHYSICAL DEFECTS 



Teachers may be guided as to the conditions requiring 
attention by reference to the following: 

Symptoms of Fever in General. — ^Headache, lassitude, lan- 
guid expression of eyes, sometimes flushed cheeks, at other 
times pallor; heat of skin and rapidity of pulse. 

Fig. 71 




Class-room inspection. 



Early Symptoms of Measles. — ^The earliest symptoms are 
those of a cold. There is feverishness, eyes are reddened,, 
watery, and sensitive to light; there is a discharge from the 
nose and the patient sneezes and coughs, the cough being of 



MEDICAL INSPECTIONS BY TEACHERS OR NURSES 305 

a dry, high-pitched character. These symptoms often last 
for three days before the rash comes out. Later a blotchy 
rash appears on the face, neck, and body. The disease is 
highly contagious even at an early stage. 

Scarlet Fever. — Scarlatina is ushered in usually by vomit- 
ing, although this may be absent. The throat is often sore 
from the beginning. There are the usual symptoms of fever. 
On the second day a red rash appears all over the body, 
the cheeks are flushed but the lips and chin are pale. 

Patients convalescent from an unsuspected scarlet fever 
returning to school prematurely may exhibit scaling hands, 
discharging ears, enlarged glands at angle of jaws, and 
prominent red elevations upon the tongue. 

Diphtheria. — The symptoms of diphtheria are those of 
fever and sore throat. There may be discharge and bleeding 
from the nose. 

Mumps. — In mumps there is a painful swelling on one or 
both sides of the face in front of the ear. 

Whooping Cough. — In whooping cough the patient has an 
ordinary cough for a few weeks, then a characteristic cough 
sets in which discloses the nature of the disease. It comes 
on in distinct spells, during which the face is puffed and 
reddened, the eyes congested and watery, and a loud whoop- 
ing sound is made; sometimes the paroxysm is followed 
by vomiting. 

Teachers can do most for the physical welfare of their 
pupils by teaching practical hygiene. Anatomy and physi- 
ology should be made interesting by practical lessons on 
healthy living. Stories which bring in lessons of hygiene 
appeal to the child and leave an impression. Rewards 
offered for periods of cleanliness are incentives to keep clean. 
Physicians should be invited occasionally to give health 
talks and if at convenient times of day, the parents can be^ 
20 



306 PHYSICAL DEFECTS 

invited to such meetings. These give excellent opportu- 
nities to discuss public health problems which advertise and 
accomplish many valuable reforms for a town. 

Teachers should always be well acquainted with the sani- 
tary conditions of their school houses and urge the abating 
of all nuisances or things prejudicial to the health of their 
scholars. 

Keeping of Records. — It is valuable for the teacher to 
keep a permanent record of the physical condition of her 
pupils. Such records should be kept on the back of the 
attendance or school report cards, and should be transferred 
from room to room or school to school with the child. Such 
record should include date of examination, condition of eyes, 
ears, nose and throat, other defects, and the date and char- 
acter of any sickness during term. This admits of a ready 
comparison of physical defects, standing in class, and 
progress in school. Many cases of non-promotion can be 
traced by the information on these reports. 

CIVIL SERVICE AND COMPETITIVE EXAMINATIONS 
FOR POSITIONS OF SCHOOL MEDICAL 
INSPECTOR. 

Several cities that have medical school officers and exami- 
ners have appointed them from eligible lists on results of 
examinations. There can be little dispute as to whether 
more efficient men are obtained in this manner. If the 
examination is practical, consisting of questions pertaining 
to the position to be filled and the examiners are unaware 
of whose papers are being marked, the results should be 
satisfactory. Men who have served provisionally in such 
appointments have an advantage insofar as knowing the 
practical work. True civil service eliminates politics and 



EXAMINATION FOR SCHOOL MEDICAL INSPECTOR 307 

favoritism. A man may be coached for an examination by 
someone familiar with the work, and thus pass with a high 
average. This is not a reflection on civil service. 

Questions for Examinations. — ^To assist civil service ex- 
aminers in preparing questions and to assist those taking 
such examinations in knowing what to study, the author 
has prepared a number of possible questions, to which 
are added the questions asked in a recent examination in 
Philadelphia. 

The branches of most importance are: public hygiene, 
pediatrics, contagious diseases, diseases of the skin, eye, ear, 
nose, and throat., 

The following are illustrations of questions which may be 
asked : 

1. What do you consider the duties of a medical inspector 
are? 

2. What instruments and other equipment should a 
medical inspector carry with him to properly perform his 
work? 

3. What has been your training since graduation that 
fits you for the position? 

4. What are the duties of a school nurse? 

5. Describe in detail a method of performing medical 
inspection to cooperate with a school nurse. 

6. What should be the equipment of a school nurse? 

7. What diseases or defects can safely be treated at 
school by the school doctor? 

8. What disease or defects can safely be treated at 
school by the school nurse? 

9. Describe a school consultation with a parent; state 
object. 

10. Describe in detail a routine examination of a pupil 
for physical defects. 



308 PHYSICAL DEFECTS 

11. Describe in detail the method of examination of a 
class for contact cases of some contagious disease. 

12. Describe the method of examinat^pn of the eyes of 
a pupil. 

13. Describe a method of examination of the ears of a 
child. 

14. Describe a method of examination of the nose and 
throat. What defects or diseases would you look for? 

15. Describe a record card which would be suitable for 
recording the defects found in a pupil. 

16. Outline a system for keeping records of work per- 
formed by a medical inspector. 

17. If you recommend treatment for a physical defect 
found in a child, and parents ignore the recommendation, 
how would you proceed to obtain results? 

18. How would you conduct an examination of the sani- 
tary condition of a school building? 

19. Mention some unsanitary conditions that may be 
found in a school building. 

20. Describe a system of heating and ventilation suited 
for a school. 

21. Outline a method of lighting a school-room containing 
forty seats. 

22. Describe the furniture which should be in a class- 
room and the location in respect to lighting. 

23. Describe an open-air school. 

24. What is a special school? What are its purposes? 
What class of children would you refer to a special school? 
To a special class? 

25. Outline a course of study suited for a mentally back- 
ward child. 

26. What are the common communicable diseases found 
among children? 



EXAMINATION FOR SCHOOL MEDICAL INSPECTOR 309 

27. What diseases may be suspected in a child with its 
throat bandaged, and how would you diagnosticate one 
from another? 

28. Give the differential diagnosis in measles, scarlet 
fever, German measles, and chickenpox. 

29. Give the differential diagnosis in chickenpox and 
variola. 

30. What action would you take if you discovered a 
child suffering from scarlet fever in a class-room? 

31. What action would you take if you discovered a child 
suffering from measles in a class-room? From diphtheria? 

32. What should be the period of exclusion from school 
of a child suffering from measles? Chickenpox? Smallpox? 
Diphtheria? Scarlet fever? Whooping cough? 

33. What diseases should be reported to the Health 
Department? 

34. Describe the technique of performing a vaccination. 

35. What constitutes a successful vaccination? 

36. When is a child immune against smallpox? 

37. Describe the method of taking a culture in a sus- 
picious case of diphtheria. 

38. When may a child who has had diphtheria return to 
school with safety to the class? In scarlet fever? In 
measles? In whooping cough? 

39. Describe a method of disinfecting a school after find- 
ing of a case of diphtheria. 

40. Describe a method of examination for vision. 

41. What inflammatory diseases may affect the conjunc- 
tiva and how would you diagnosticate one from the other? 

42. Describe a case of trachoma. 

43. How would you test the vision of an illiterate? Of 
a feeble-minded child? 

44. Describe a method for testing hearing of a child. 



310 PHYSICAL DEFECTS 

45. What diseases may cause earache? 

46. What diseases may cause a swelHng of face or neck? 

47. Describe a method for testing speech. 

48. What defects may occur in breathing and mention 
their causes? 

49. Name the five commonest and most prevalent dis- 
eases of the skin occurring in children. Diagnosticate one 
from the other. 

50. Describe three skin diseases which are contagious. 

51. Describe the symptoms of two common nervous dis- 
eases occurring in children. 

52. What are the causes and treatment of lateral curvature 
of the spine? 

53. What systemic diseases would debar a child from 
taking part in the physical exercises at school? 

54. Name the physical defects which may cause a sub- 
normal or mentally defective child. 

55. Outline a method of inspection for diagnosticating 
mental deficiency. 

56. Describe the Binet tests. 

57. What recommendations would you offer for a sub- 
normal or retarded pupil? For a mentally defective pupil? 



COMPETITIVE EXAMINATION FOR SCHOOL MEDICAL 
INSPECTOR HELD IN PHILADELPHIA. 

1. What in your opinion are the two most important 
acute throat infections, and how would you diagnosticate 
them? 

2. What are the principal etiologic factors in acute 
middle-ear infections occurring in children, and how make 
early diagnosis of the ear involvement? 



EXAMINATION FOR SCHOOL MEDICAL INSPECTOR 311 

3. What objective symptoms would lead you to believe 
that a child is in need of nasal treatment? 

4. Name the contagious diseases of the eye or its appen- 
dages, and give in detail technique of examination. 

5. Give age at which chlorosis occurs most frequently; 
its causes; the symptoms and blood conditions. 

6. Mention the causes of backache in young girls aside 
from that due to pelvic disease. 

7. State symptoms which would cause you to suspect 
the existence of an eruptive fever in its early stage. 

8. State causes which would determine you to exclude 
children from attending school. 

9. Describe a routine method of school medical inspec- 
tion, including inspection, methods of heating, Hghting, 
ventilating, cleaning, exercise, and physical examination. 

10. Draw a simple diagram of and described an ideal 
school-room, with furniture, for twenty children of about 
fourteen years of age. 

11. Describe briefly a fresh-air school, such as would be 
possible in the centre of a city of the first class, and outline 
the course of treatment given to a pretubercular child of 
fourteen years attending it in winter. 

12. A teacher reports a girl of fifteen as being deficient 
in her studies; outline a practical investigation giving five 
possible reasons for such a condition, with a brief treatment 
of the cause as finally determined. 



INDEX. 



Abdominal pain, 244 

Absentees and contagion, 140, 148 

in New York City, 149 
Abuse of test cards, 191 
Accommodation, 192, 256 
Acuity of hearing, 170 

of vision, 169 
Additional work during summer, 35 
Adenoids, diagnosis of, 203 

ill effects of, 205 
Adjustable desk and chairs, 121 
Adjusting eye-glasses, 194 
Administration, 23 
After-training of inspectors, 32 
Air, purity of, in class-rooms, 126 

space in class-rooms, 115 
Analysis of air in class-room, 127 
Anemia, 244 
Anemometer, 129 
Antitoxin for diphtheria, 158 
Aphasias, 206 
Appendicitis, 244 
Appointment of inspectors, 31 
Arrangement of seat and desk, 120 
Artificial light in class-room, 116 

lighting. Dr. Myles Standish speci- 
fications on, 116 
Audiometer, 197 
Auxiliaries to school inspection, 82 



Bacteria, sources of entrance of, 

into body, 139 
Bags, equipment of, for nurses, 47 
Basement of school building, 99 
Beginning of school inspection in 
America, 18 
in Europe, 18 
Binet tests of mentality, 262 
Blepharitis, treatment for, 56 
Blepharospasm, 176 
Blotter for oflSce control, 82 



Body, pediculosis of, 240 
ringworm of, 237 

Boston schoolhouse commission desk- 
chair, 121 

Building and grounds, 93 

inspection of sanitation, 93 
construction of, 98 
requirements, laws on, 104 

Buildings, cleanliness of, 117 

Bureau of Child Hygiene, 38 
in New York City, 40 



Cabdiac insufficiency, 244 
Carriers of diphtheria, 156 
Causes of non-promotion, 261 

of retardation, 251 
Certificate of vaccination, 154 
Chairs and desks, types used, 119 
Chandler adjustable desk and chair, 

121 
Chicago, report of school inspection 

in, 167 
Chickenpox, diagnosis of, 160 
Child hygiene, bureau of, 38 

in New York, 38 
Chorea, 243 

Circular of instruction to teachers, 304 
Cities employing school nurses, 58 

physicians, 58 
Civil service examinations, 306 
questions, 307 

in Philadelphia, 310 
Classes, special, for retarded children, 

299 
Class-room inspections, 64, 140 

lighting of, 116 
Class-rooms, 115 

Cleanliness of school buildings, 117 
Clinics and laboratories for study of 
mentality, 301 

for school children, 78 
Closet for supplies, 34 

and lockers, 117 
Cold-room schools, 131 



314 



INDEX 



Communicable diseases, 135 
Conjunctiva, inspection of, 176 
Conjunctivitis, diagnosis of, 172, 177 
follicular, 178 
phlyctenular, 178 
treatment of, 56 
Construction of buildings, 98 

ten commandments for, 99 
Consultations with parents, 49 
Contagious diseases, 135 

action taken by inspectors, 141 
methods of detection, 139 
prevalence among children, 137 
training inspectors in, 136 
transmission of, 139 
skin diseases, 236 
Copy books and vision, 196 
Corneal ulcers, 177 
Cost of medical inspection, 24 

of public education, 17 
Cotton, Dr. F. J., desk and chair, 121 
Cultures for suspicious diphtheria, 

157 
Cups for drinking water. 111 
individual drinking, 113 
made by pupils, 115 . 
Curvature of spine, 230 



Defective breathing, 244 

hearing causing retardation, 253 
vision, 184 

causing retardation, 253 
and mentality, 297 
prevalence of, 184 
symptoms of, 192 
Definition of terms on contagion, 138 
Dental clinics, 86, 208 
forms used in, 211 
in Philadelphia, 210 
Desks and chairs, good and bad 
types, 119 
stationary, 122 
relation of chairs to, 120 
Diagnosis of diphtheria, 156 
of measles, 159 
of mumps, 161 
of pertussis, 160 
of rubella, 160 
of scarlet fever, 158 
of smallpox, 151 
of varicella, 160 
Diagnosticians, 136 
Diphtheria antitoxin, 158 
carriers, 156 
diagnosis of, 156 
Director, duties of, 36 
qualifications of, 35 
training of, 36 



Diseases of ears, 200 

of eyes, 171 

of nervous system, 242 

of nose and throat, 200 

of skin, 235 
Disinfection, methods of, 147 
Dispensaries and hospitals, 87 
Dispensary visits with nurse, 51 
Dixon, Dr. S. G., on prevalence of 

contagion, 137 
Drainage and plumbing, 109 
Drinking fountains and cups, 111 

water, 110 
Dust prevention, 118 
Duties of director, 35 

of inspectors, 32 

of principal in inspections, 82 

of school nurses, 46 

of supervisors, 36 

of teachers in inspections, 82 



E 



Ears, diseases of, 200 

hygiene of, 200 

inspection of, 197 
Education, cost of public, 17 
Enlarged tonsils, 203 
Epilepsy, 242 
Equipment of inspectors, 33 

of nurses, 47 
Eruption of teeth, 217 
Examination, civil service, 306 

competitive in Philadelphia, 310 

of individual pupils, 66 
Exclusions, form for, 75, 143 

period of, 144 

and quarantine, 142 
Executive ability of director and 

supervisors, 37 
Eye clinics, 86 

everting lid of, 176 
Eye-glasses, adjusting, 194 
Eyes, diseases of, 171 

hygiene of, 196 

legislation on examinations of, 185 

methods of examination of, 174 

prevalence of diseases of, 171 

strain of, 192 



Favus, 237 

Feeble-minded children, 249 

Vineland, N. J., institution for, 201 
Filing records, 76 
Fire escapes, 109 

safety against, 108 
First school inspection in America, 20 



INDEX 



315 



Foreign bodies in nostrils, 201 
Foreigners, card for testing eyes of, 

189 
Follicular conjunctivitis, 178 
Formalin - aluminum - sulphate lime 

disinfection, 148 
Form for dental examinations, 210 

for exclusions, 75, 143 

of placards, 147 

for recording defects, 73 

for referring to clinics, 78 

for reporting sanitation, 96 

for reports of inspectors, 79 

for return of pupils, 144 
' for weekly report of nurses, 77 
Foul breath, 202 

Frequency of visits of inspectors, 67 
Furniture, Dr. Jas. W. Sever on, 118 

for class-rooms, 118 



G 



General considerations, 23 
German measles, diagnosis of, 160 
Goddard, Dr. H. H., Binet tests for 

mentality, 262 
Grounds and building, 93 
Guide for teachers, 304 



H 



Head, pediculosis of, 239 
Hearing, testing, 170, 197 
Heating and ventilation, 126 

systems of, 130 
History of medical inspection, 19 

of school nursing, 19 
Home sanitation, 248 

surroundings, environment, and 
retardation, 252 

visits by nurse, 53 
Hordeolum, 174 
Hospitals and dispensaries, 87 
Humidity of class-rooms, 129 
Hutchinson's teeth, 162 
Hygiene of ears, 200 

of eyes, 196 

personal, 248 

teaching of, 83 

of teeth, 208, 215 

text-books on, 85 
Hypertrophied tonsils, 203 
Hysteria, 243 



Idiots, 249 

Illiterate test card by author, 187 

Imbeciles, 249 



Impetigo, 239 

treatment of, 56 
Individual cups made by pupils, 115 

examinations, 66 
Infectious diseases, 135 
Inspection, auxiliaries to, 82 

of class, 64 

of cleanliness of buildings, 118 

of ears, 197 

of eyes, 174 

of nose and throat, 200 

of sanitation of buildings, 118 

systems of, 62 

of teachers and janitors, 90 
Inspectors, after-training of, 32 

appointment of, 31 

duties of, 32 

equipment of, 33 

kinds of, 23 

number required, 30 

qualifications and training of, 31 

report sheet, 79 

salary of, 25 

volunteer, 23 
Institutions for feeble-minded, 300 
Instructions for treatment of pedicu- 
losis, 55 
Iritis, 175 
Itch, 237 



Janitors and cleanliness of buildings, 
117 
inspection of, 90 



Keratitis, 173 
Koplik's spots, 160 
Kyphosis, 233 



Laboratories for study of men- 
tality, 301 

Lacrymal apparatus, 175 

Laws on building requirements, 104 
on medical inspection, 25 

Legislation on examination of eyes, 
185 
in Pennsylvania, 26 

on building requirements, 104 
on playgrounds, 108 
on public drinking cups. 111 
on school inspection, 25 

lice on head or body, 239 

Lighting, artificial, for class-room, 116 
of class-rooms, 116 



316 



INDEX 



Lighting, Dr. Myles Standish's speci- 
fications for, 117 

List of open-air schools in United 
States, 132 

Lockers and closets, 117 

Lordosis, 233 

Lunches at school, 246 



M 

Maintenance, cost of, 24 
Malformations of oral cavity, 206 
Malnutrition, 244 

Massachusetts laws on common 
drinking cups. 111 
on vaccination, 153 
McCullough, Dr. P. B., on treatment 

of teeth, 222 
Measles, diagnosis of, 159, 172 

German, 160 
Medical inspection, cost of, 24 
by teachers or nurses, 302 
objects of, 22 

inspectors, 29 

progress, 18 
Meetings for parents, 86 
Mental and physical relations, 18 

defective, treatment of, 296 
Mentality, 248 

Binet tests for, 262 

classification of, 249 

clinics for studying, 301 

and defective vision, 297 

examinations of, 257 

and non-promotion, 260 

records of examinations of, 259 
Methods of detection of contagious 
diseases, 139 

of transmission of contagions, 139 
Mumps, diagnosis of, 161 
Mydriatic, use of, 193 



N 



Neevotjs system, diseases of, 242 
New York City, absentees and con- 
tagion in, 149 
Child Hygiene Bureau, 40 
report of school inspection in, 

168 
trachoma reported in, 180 
Non-promotion and mentality, 260 

causes of, 261 
Nose and throat, inspection of, 200 
Nosebleed, 202 

Notification blank for defects, 49 
Number of inspectors required, 30 

of nurses required, 30 
Nurses, appointment of, 44 



Nurses, cities employing, 58 
duties of, 46 
employment of, 47 
history of school, 19 
medical inspection by, 302 
number required, 30 
qualifications of, 45 _ 
report in Philadelphia, 60 
results obtained by, 59 
salary of, 25 
value of, 56 

Nystagmus, 176 



Objects of medical inspection, 22 
Odontalgia, 225 
Office control of work, 37 
Open-air schools, 131 

list of, in United States, 132 

types of, 131 

value of, 133 
Oral cavity, malformations of, 206 
Orthopedic defects, 229 
Outing camp at Algonquin, 131 



Pallor, 244 

Parental schools, 299 

Parents and school inspection, 86 

meetings, 86 
Pediculosis of body, 240 

circular of instructions, 55 
of head, 239 
Pemphigus of eye, 175 
Pennsylvania, legislation on school 
inspection, 26 
school building, requirements in, 
104 
code, 26 
Period of exclusion for contagion, 144 
Permits for vaccination, 155 

from parents for treatment, 51 
Personal hygiene, 248 
Pertussis, diagnosis of, 160 
Pharyngitis, 156 

Philadelphia, competitive examina- 
tions in, 310 
dental school clinics, 210 
report of school nurses in, 60 
trachoma reported in, 181 
work performed by inspectors in, 
166 
Phlyctenular conjunctivitis, 178 
Physical and mental relations, 18 
defects causing retardation, 253 
general considerations of, 165 
method of inspection for, 167 



INDEX 



317 



Physicians in educational affairs, 18 

salary of school, 25 
Pinguecula, 175 
Placards, 146 
Plans of school building in Toledo, 

102 
Playgrounds, 108 
Plenum system of ventilation, 130 
Plumbing and drainage, 109 
Precocious children, 249 
Prevalence of contagious diseases, 
137 

of retardation, 251 
Principal duties in inspection, 82 
Pterygium, 175 
Ptosis of eyelids, 175 
Puffiness of eyelids, 173 
Pupils, unequal, 173 



Qualifications of director, 35 

of inspectors, 31 

of school nurses, 45 

of supervisor, 36 
Quarantine and exclusions, 142 
Quarantined house, leaving, 146 
Quinsy, 202 



R 



Records and record keeping, 68 

filing of, 76 
Relation of mental to physical con- 
ditions, 18 
Report blank for inspectors, 79 
for nurses, 77 
for sanitation, 96 

on sanitation of buildings and 
grounds, 95 

of school nurses in Philadelphia, 60 
Results obtained by school nurses, 59 
Retardation, 249 

causes of, 251 

prevalence of, 251 
Retarded children, treatment of, 296 
Ringworm of body, 237 

of scalp, 236 

treatment of, 56 
Room in school for inspections, 34 
Rubella, diagnosis of, 160 



Safety against fire, 108 
Salary of school inspectors, 25 

nurses, 25 
Sanitation of buildings and grounds, 
93 



Sanitation of homes, 248 

reports on, 95 
Scabies, diagnoses of, 237 

treatment of, 56 
Scalp, ringworm of, 236 
Scarlet fever, diagnosis of, 158 
School cold room, 131 
consultations, 49 

inspection, beginning of, in Amer- 
ica, 18 
in Europe, 18 
cost of, 24 
history of, 19 
legal definition of, 157 
lunches, 246 

nurse, appointment of, 44 
duties of, 46 
in England, 19 
equipment of, 47 
history of, 19 
number required, 44 
organization of, 42 
qualifications of, 45 
Schools, open-air, 131 
special, 300 

treatments by nurse, 54 
Scoliosis, 230 
Seating of pupils, 119 
1 Sever, Dr. Jas. W., on school furni- 
ture, 118 
Sex hygiene, teaching of, 247 
Site for city schools, 106 
i for rural schools, 105 
\ Skin diseases, 235 

treatment of, 240 
Smallpox, diagnosis and prophylaxis 
of, 151 
symptoms of, 150 
Social visitors, 89 
Source of cases, 71 
Special classes and schools, 299 

school clinics. 87 
Specialists, 87 
Specific infections, 138 
Speech, defects of, 206 

normal, 206 
Spinal curvature, 229 
Springfield drinking fountain, 114 
Squint, 176, 182, 194 
Stairs, construction of, 99 
Standish, Dr. Myles, specifications 

of artificial lighting, 116 
Stationary desks and chairs, 122 
Stoop shoulders, 233 
Strabismus, 175, 182, 194 
Stuttering, 206 
Subnormal child, 249 
treatment of, 296 
Summer work, 35 
Supernormal child, 249 
Supervision of inspectors, 24 



318 



INDEX 



Supervision of nurses, 45 
Supervisors, duties of, 36 

qualifications of, 35 

training of, 36 
Syphilis, 162, 202 
Systemic diseases, 243 
Systems of heating, 130 

of inspection, 62 
by author, 72 



Teacher, duties of, in inspection, 82 

inspection of, 90 

medical inspection by, 302 
Teaching hygiene, 83 

sex hygiene, 247 
Teeth, examination of, 207 

eruption of, 217 

hygiene of, 208, 215 

shape of, 217 

treatment of, 222 
Temperature of class-rooms, 129 
Test card, abuse of, 191 

by author for illiterates, 187 

for foreigners, 189 
methods of examining with, 189 
value of, 186 
Temporary teeth, 226 
Text-books and eye-strain, 196 

on hygiene, 85 
Thermometers in class-rooms, 130 
Throat and nose, inspection of, 200 

sore, 156 
Toilets and urinals, 110 
Toledo drinking fountains, 112 

plans of school building in, 102 
Tonsils, hypertrophied, 203 
Trachoma, 173, 179 
Training in contagious diseases, 136 
and qualifications of inspectors, 

31 
of director, 35 
of supervisors, 36 
Transmissible diseases, 138 
Transmission of contagion, 139 
Treatment for blepharitis, 56 

for conjunctivitis, 56 

for impetigo, 56 

by nurse at school, 54 

for pediculosis, 55 

for ringworm, 56 

for scabies, 56 



Treatment of skin diseases, 240 

of teeth, 222 

for wounds, 56 
Truants, cause of, 20 
Tuberculosis, 162 
Types of open-air schools, 131 



Ulcers on cornea, 177 
Unequal pupils, 173 
Uniform for nurses, 47 
Urinals and toilets, 110 



Vaccination, 151 

certificate of, 154 

legislation on, 153 

operation for, 152 

permit for, 155 
Vacuum system of ventilation, 130 
Value of open-air schools, 133 

of school nurses, 56 
Varicella, diagnosis of, 160 
Venereal diseases, 247 
Ventilation and heating, 126 

kinds of, 127, 130 
Vineland, N. J., institution for 

feeble-minded, 301 
Vision, prevalence of defects of, 184 

testing, 169 
Visiting nurses, 19 
Visits, number of, by inspectors, 67 
Voice, defects of, 203 
Volunteer inspectors, 23 
Vomiting in school, 158 



W 

Waldschulen, 131 

Walls and wood- work, 116 

Watch test for hearing, 170, 197 

Water-supply, 110 

Wessels, Dr. L. C, on defective 

vision, 297 
Whispered voice test for hearing, 170, 

199 
Whooping cough, diagnosis, 160, 172 
Windows in class-rooms, 116 
Work performed hy nurses, 48 
Wounds, treatment for, 56 



NOV 18 1913 



